Dr Afzal Mahmood

Dr Afzal Mahmood

Documents Reviewed
Examples: Kaltim Provincial Maternal Health Profile 2010 Kukar Department of Health Report Evaluation Report (Presentation) Program Kesehetan Keluarga, 2009 Kukar Laporan PWS KIA, December 2010 Kutai Kertenegara Health Profile 2009 Kukar Data Maternal Deaths 2009, 2010 Kukar Maternal Death case study from one puskesmas catchment area Kukar Infant Mortality Data Data dasar kesehatan ibu, Paser Paser Data Maternal Deaths 2009, 2010, Neonatal death case study from one puskesmas Paser Maternal and Infant Mortality Data Paser Presentation and data provided by four puskesmas (Tanah Grogot, Muara Komam, Paser Belengkongaser, Long Kali) Kutai Barat ..................................................
Dr Afzal Mahmood

Interviews & Discussions

Puskesmas & Community based government Private Midwifes from across the district, Hospital based midwifes and dotors, Head of Puskesmas, Dinkes, Provincial Department of Health Puskesmas & Community based government and private midwifes from across the district Hospital based midwifes and doctors Head of Puskesmas Dinkes, Provincial Department of Health, and Academy of Midwifery Training Kukar staff
Dr Afzal Mahmood

Visits & Situation Analysis

Urban & Rural puskesmas, review of information and discussions with staff Visits to Hospital: maternity care information review, discussion about links between Dinkes & Hospital

Dr Afzal Mahmood

Maternal Health Context: Kaltim

Provincial and districts Maternal and Child Health Program, under the vision Indonesia Sehat 2010, prioritise maternal and infant mortality reduction, provision of safe and high quality antenatal, intrapartum and postnatal care. Major strategies include actions that each delivery is assisted by appropriately skilled health personnel, the capacity to provide adequate care for obstetrics and neonatal complications, management of complications of miscarriage, and reduction in unwanted pregnancies. Indicators to assess the success include the number of antenatal visits, proportion of deliveries by skilled personnel, effective management of obstetrics complications, contraceptive prevalence rate. The focus is on the improvement of services at the primary care level, increasing the number of skilled personnel, placement of midwives in rural and remote areas, provision of incentives for provision of care to pregnant women and mothers, training of traditional birth attendants, working with the skilled birth attendant in the private sector and with the traditional birth attendants, and efforts to improve the referral system.
Dr Afzal Mahmood

Current situation
Success in terms of improved access, high rate of ANC (92% K1 and 80% K4 in Kaltim in 2009). Overall, 80% deliveries conducted by the skilled attendants. The overall rate of deliveries by dukun in Kaltim has decreased to only 8.7% by 2009 (except in Nunukan and Kukar where dukuns still conduct about 18 and 19%). In Paser and Kubar only 6% and 8% deliveries were conducted by dukuns in 2009.
However, despite these effort the maternal mortality is still high Need for much improvement in other pregnancy outcomes as well. Many women suffer from complications during pregnancy and delivery for which they often find it difficult to access services. One major challenge is to provide adequate and high quality care in rural and remotes areas.

Dr Afzal Mahmood

Strengths
POPULATION Relatively small population size Relatively less absolute poverty due to population size, mining, infrastructure development with opportunities for jobs and businesses HEALTH SYSTEM A network of services which are strategically located for universal coverage and ease of access Motivated senior managers and program coordinators at Dinkes level, with good understanding of local issues A large number of staff (nurses, bidan, doctors, admin staff) Young, motivate able workforce Existing links with a large number of community volunteers
Dr Afzal Mahmood

Strengths
POLITICAL DECISION MAKING Good interaction between district government and district health departments Approachable politicians Provincial government and Provincial Department of Health keen to support districts for policy and regulation changes, as well as for technical assistance to improve maternal health MATERNAL AND CHILD HEALTH Maternal mortality on the decline High coverage of ANC, PNC, TT, deliveries by the trained staff Many women approaching district hospitals for ANC/deliveries

Dr Afzal Mahmood

Current Approach
The current approach to promote mothers and children is about access to skilled birth attendants for all pregnant women in the district. The strategies within this approach include recruitment of trained midwives, on the job training for the midwives, improving puskesmas services for EmOC, and improving referrals for pregnancy and delivery complications.

Dr Afzal Mahmood

Findings
Reported deliveries by Trained birth attendants in the three districts about 80% K1 78% to 85%, K4 60% to 80% High KN1 and KN2 rates (60-80%) There are however issues with the targets provided by the Bureau of Statistics Nakes reported 20% women as having one or more risks for pregnancy or delivery Majority of the reported maternal deaths in hospitals (for example out of 9 deaths in Paser 7 in hospital, and out of 27 in Kubar 17 in hospitals) Many deaths among 30-39 years of age Many deaths in those areas that are only two/three hour distance from hospitals

Dr Afzal Mahmood

Findings
So far no review conducted to explore reasons and circumstances beyond the immediate cause (such as haemorrhage, hypertension etc),
other serious illnesses, too many pregnancies too short period between the consecutive pregnancies, complications during previous pregnancies how those complications were managed.

Information about other pregnancy outcomes such as intrauterine growth retardation, early rupture of membranes is not available.

Similarly, the information on complications, complications during postnatal period, interval between pregnancies, contraceptive use by those who have delivered babies in the last year is not available.
Dr Afzal Mahmood

Findings: Planning and Management Capacity

Insufficient management capacity: for example reporting delays, misallocation of resources (for example availability of 19 bidans at one puskesmas covering a population of about 6000), lack of planning to proactively serve those pregnant women who are at high risk of complications, lack of attention to factors such as contraception, inadequate attention to resolve the referral delay issues, Lack of capacity at puskesmas and dinkes level to plan and improve condition of facilities/ambulances/labour room/supplies for emergency obstetrics care. Inadequate capacity to use local data for local puskesmas based planning. Need for capacity to review the current situation/trends and plan for the needed change. Kepala puskesmas and bidan coordinators require skills for local planning, and effective management of resources (human resources and facilities) for which they are responsible.
Dr Afzal Mahmood

Findings: Planning and Management Capacity

Focus on achieving the input and process targets (ANC visits, number of postnatal visits, delivery by skilled attendants). As the focus is on extending the coverage the focus on quality of care of these human resource is less the optimum. Dinkes, at present, does not have sufficiently trained enough number of staff who could provide planning and management support to kepala puskesmas or bidan coordinators. Generally, the quality improvement efforts are limited to training of the staff at a hospital or university The capacity is also limited because of lack of delegation of authority to Dinkes about resource planning and allocation decision; for example the decisions about the number of staff needed, appointments, placement, type and place of training etc.

Dr Afzal Mahmood

Findings: Data quality and use

The review found little evidence of the use of data for management purposes. At present the data is mainly used for projecting targets for the next year. For example, the coverage of various services vary across different regions within the district. However, the data at present is not reviewed to highlight this and then to work with the concerned puskesmas teams to improve the performance.

Dr Afzal Mahmood

Findings Data quality & Use

Issues with the targets supplied by the Bureau: The projected targets received from the Bureau are not confirmed through home visits, nor do all pregnant women visit the centres. In fact utilisation of centre-based services by the pregnant women is very low. The staff also relies on private midwifes to report data; however, puskesmas midwifes mentioned that not all high risk pregnancies, deliveries or complications are reported.
K1 and K2 Information is also unreliable For example, at Puskesmas XXXXX the Bureau target for Bumil was 177 and target for deliveries was 166. The puskesmas staff however was able to record only 98 deliveries, which they believed is the correct number. The staff in XXX insisted that their data accounts for all the deliveries in the area. If the 420 number was correct, and if Bureau of Statistics projects are incorrect by similar margin across the whole district, then the actual number of births might be quite low compared to the estimates. Such as situation poses serious challenge for health services and human resource planning. At present this is difficult to judge if the puskesmas are unable to record all deliveries in all areas. Regardless, this situation presents challenge for local service planning. Dr Afzal Mahmood

Recommendation: Quality of Care

Continuation of excellent coverage already achieved: There is a need to improve the quality of the services provided by the existing staff, and for which resources are required. Follow up care for those who are identified as having high risk pregnancies: In one area, for example, almost half of the pregnant women were diagnosed with one or more risks. However, the bidans did not refer the patients to doctors and did not involve the puskesmas doctors for needed treatment. Support to bidans for better health education and counselling: Despite a large number of contacts with pregnant women, perception about hospital use and the role of family towards care for pregnant women are not influenced.
Dr Afzal Mahmood

Quality of intrapartum care

Equipment Needs: It was highlighted by the puskesmas staff that rural puskesmas lack dopplers, oxygen supplies, bidan kits, blood transfusion facilities. All puskesmas in rural and remote areas should be ready to provide EmOC and that the midwives placed there should be fully trained to provide basic EmOC. Neonatal resuscitation, blood transfusion and eclampsia management training is needed for the midwives. Policy and Protocols to Use Bidan Skills: Some Bidans are trained and some of them have experiences for providing additional needed services during pregnancy and delivery. Examples of these interventions include blood transfusion, management of haemorrhage, labor induction, manual removal of placenta, and IUCD insertion. However, the current regulation does not allow bidan to use these skills even when these interventions are needed and where referral is difficult or is refused by the family Coordination with Hospital: Dinkes should interact with, and preferably place one coordinator at the hospital, hospital for data on delivery outcomes, and arrange for follow up visits for those mothers who have complications during pregnancies and for babies who are born with low birth weight or other complications/diseases or congenital problems.

Dr Afzal Mahmood

Recommendations: Improve Resource Management

Basic Emergency Obstetrics Care: at puskesmas that are more than 2 hour drive from the hospital, with both doctor and midwife trained to manage basic obstetrics complications, with adequate labour room facilities. Supervision of Puskesmas: Dinkes mid level managers should visit puskesmas regularly and work with the Kepala Puskesmas and Bidans to provide support for planning Support & supervise midwives for a focus on prevention of diseases (e.g. malaria, worm infestation), health education, planned pregnancies with appropriate duration, identification of risk and referral of neonates. The responsibility focus should be on pregnancy outcomes rather than only on ANC visits and delivery by skilled attendant

Dr Afzal Mahmood

Recommendation: Planning and Management Capacity

Strengthen Service Planning Capacity at Puskesmas level. Management training , ongoing support and review (by Dinkes) for kepala puskesmas and bidan coordinators on how to utilise local information for targeting management of high risk pregnancies, follow up and home visits
Dinkes train existing staff and appoint additional skilled staff to strengthen its management capacity Consider incentives for skilled senior midwives for placements and continuation of service in rural & remote areas.
Dr Afzal Mahmood

Recommendation: Coordination with the local hospitals

Develop SOP and agreements between Dinkes and hospital about exchange of referral and follow up information between the hospital and pusban/puskesmas/polindes Utilise the local hospital for placement/training of dinkes bidan and doctors

Dr Afzal Mahmood

Recommendation: data for local planning

Need to improve dinkes and puskesmas management capacity to review, analyse data and use it for planning Validate the information by conducting census in catchment areas of some of the puskesmas and then identify if the Dinkes information is incorrect or if the Bureau of Statistics estimates need to be changed.
Interact with the Bureau of Statistics to discuss the situation
Dr Afzal Mahmood

Recommendation: Quality of ANC

Plan regular home visits particularly for those at high risk, and plan for regular support visits by bidan coordinators. Train Kepala puskesmas for such management skills Develop and monitor the implementation of specific protocols on how to manage high risk pregnancies. Involve Kepala puskesmas and doctors at the puskesmas Assign responsibility and train puskesmas doctors to work with bidans/perawat For example, puskesmas doctors should be involved in the care of those women who have HTN or past history of eclampsia, eclampsia or other complications in the past. Improve quality of communication and health education. Home visits will contribute to this process if home visit are planned carefully.

Dr Afzal Mahmood

Ref System
Dinkes should make sure that the ambulances are functional (equipment, staff, driver, petrol) and available 24 hours a day and are available at no more than two hour distance for a comprehensive EmOC centre Where needed, Puskesmas should be provided with an appropriate vehicle for staff movement. Communities, Posyandu volunteers, Pustus, Polinkams staff should have access to the phone number of nearby functional ambulance. Dinkes staff should visit the puskesmas when a death is reported, review the information regarding ref & delays and plan to avoid future occurrence of such reasons.
Dr Afzal Mahmood

Recommendation: Quality of Intrapartum Care

Puskesmas: Plan and implement a system of following up (phone, and home visits) high risk women during the last week of pregnancy Doctors at puskesmas that have Basic/Comprehensive EmOC should be trained to provide clinical care to those who suffer from delivery complications. Dinkes to review the condition at Puskesmas on a regular basis (availability of equipment, maintenance of equipment and ambulances, building). Regularly collect and review information on pregnancy outcomes
Dr Afzal Mahmood

Recommendation: Dukuns
Puskesmas should identify the families that still use dukun, and analyse the reasons for such reliance on dukuns Dinkes should compare the complication rate and poor pregnancy outcomes for those cared by the midwives and those cared by dukuns

Dr Afzal Mahmood