Innovation for access in Indonesia

Reducing maternal mortality

It’s raining outside the health center in Jayapura, in Papua, Indonesia, as women wait to be seen by a midwife. Noisy cars and mopeds pass by while lush, dense forests are visible in the distance. Lydia Simanjuntak, one of the patients in line, smiles as she describes what it was like to have her first ultrasound and how happy she was when she heard a heartbeat. At seven-months pregnant, this was only her second visit; she said she wasn’t aware that the health center had an ultrasound machine, so had previously visited the pharmacy and paid the equivalent of $80 for a checkup. But when she heard that the facilities in the center were free, she decided to pay a visit.

The bigger picture

Indonesia’s vast scattering of over 17,000 islands — of which some 8,000 are inhabited — have some of the highest rates of maternal mortality in Southeast Asia. One of the biggest factors affecting the rate of maternal deaths is a lack of access. Local midwives in remote corners of the country are on the front lines of primary care, but are not necessarily adequately trained, with a dearth of specialist obstetricians and gynecologists. Many women in poor and rural settings don’t have access to such care, and even when services are accessible the quality can be variable.

Maternal mortality remains a global issue. Despite a significant reduction in recent years — falling by half between 1990 and 2015 — 216 women per 100,000 live births still die each year. Now, under Sustainable Development Goal 3, good health and well-being, the United Nation’s target is to reduce the number of women dying due to complications from childbirth to less than 70 per 100,000 live births. This is a huge challenge, and one that many countries are struggling to meet, particularly those such as Indonesia, where the numbers fell by just 5 percent in the same time period.

A look inside Papua

In Papua, at the easternmost edge of Indonesia and among the least developed provinces in the country, a lack of health care infrastructure is cause for concern. A report from Human Rights Watch notes that Papua has Indonesia’s highest infant, child, and maternal mortality rates. But in Jayapura, the province’s capital, steps are being taken to counter this problem in primary health centers at the heart of the communities. 

Jayapura city, the capital of Papua province

These government-mandated centers — puskesmas, in Indonesian — are dotted around the sprawling city and its surrounding peri-urban areas. One of these centers, Puskesmas Waena, is tucked down a narrow street on the outskirts of the city, and visited by around 365 pregnant women per year — each of whom is entitled to four free checkups over the course of their pregnancy.

Dr. Yani Kurniati, general practitioner at the center, said maternal mortality, primarily caused by unexpected complications during pregnancy, is still the biggest challenge that the center’s medical practitioners — one GP and seven midwives — face. This, she said, is partly due to a lack of coherent data collection and record tracking, which result in potential undetected complications. The checkup process sees midwives conducting the first examination, and the GP the more thorough consultations including ultrasounds and prescriptions. If necessary, the patient is referred to a specialist in this field who would be called into the center.

“There are criteria around when a patient should be referred, and when the referral takes place — sometimes the connection stops at that point,” Kurniati told Devex, noting that there was still a lack of communication between the center and the hospital. “Sometimes the patient doesn’t come back to the clinic, and the hospital doesn’t have the responsibility to inform back to the clinic. This makes tracking the conditions of the mother fall apart.”

Digital interventions

Despite referrals, the drop-off rate in the puskesmas is high, making data collection all the more essential. Health technology company Philips partnered with the local government and telecommunications company Telkom to launch its Mobile Obstetrics Monitoring system, or MOM. Following a checkup, the patient’s data are entered into a system that organizes and classifies them. Data can be accessed anywhere, any time, and if there is any cause for concern the system automatically raises a red flag.

"It makes it much easier to track the health 
of the mother — we know what status it 
needs to be." 
Dr. Yani Kurniati, general practitioner at Puskesmas Waena

“It makes it much easier to track the health of the mother — we know what status it needs to be,” said Kurniati. “It’s a very effective system to help us know the high risks of the pregnancy so we can take the necessary actions.”

The center also replaced its previous ultrasound machine with a Philips portable device, complete with a battery to counter the frequent power outages. Kurniati said the quality of the resolution is higher, and emphasized the importance of this in determining the health of the fetus — and whether or not the mother needs to be referred. The device, she added, can also be used for abdomen checks for other patients.

Improving access in remote areas

Before launching the program in Jayapura in early 2017, Philips worked with health centers in West Sumatra on a yearlong pilot project in 2014. But the context in Papua is much more challenging due to the remote locations where some of the patients live, said Suryo Suwignjo, president director of Philips Indonesia. In 2016, the drop-off rate was 14 percent and, as a result, midwives often have to conduct home visits by moped to ensure that pregnant women are receiving access to the checkups they are entitled to. 

Midwives often have to conduct home visits by motorbike to make sure pregnant women are getting regular check-ups.

Libra Padaunan, a midwife at Puskesmas Waena, travels by moped to visit a patient

While the midwives are still being trained to use the MOM system and the ultrasound device, some feedback on the pilot project has already been implemented to make it more useful in these areas: the MOM app now has an offline function, for example, so that data can be collected even if there is no cellphone reception. Ultimately, the MOM system aims to ensure that the remote location of a patient or a health center does not necessarily mean a lower standard of care, said Suwignjo, and when the midwives make referrals to specialists based in other parts of Indonesia the result is more efficient and effective.

“If any irregularities are flagged by the system — for example, weight or waist size — a doctor based in, for example, Jakarta [more than 2,000 miles away] can immediately alert the midwife and instruct them on what to do,” he said. “This means that the rate of losing the pregnancy or mortality during the delivery can be very much reduced.”

This is particularly important in a province with a scarcity of doctors and paramedics, most of whom gravitate to the bigger cities due to better work opportunities and quality of life.

“Can you imagine if there is no specialist in the remote areas? The people living there would have to travel far to get an adequate service,” said Suwignjo. By introducing remote diagnostics to this peripheral area, he said, this partnership can contribute to the Indonesian health care system.

The center’s holistic approach

An overarching aim of the project is to boost the confidence of the midwives. Their skills and knowledge have already improved, said Kurniati, thanks to the exchange of information between them and the obstetricians and gynecologists. As well as learning more about the digital data collection system, midwives have been trained to administer HIV tests, which are free for pregnant women but which midwives were previously reluctant to perform.

Training has been a key part of improving the quality of primary care in the center as a whole and of attracting women to attend their checkups.

Philips' Herman Sujito conducts a demonstration for health workers of the new Mobile Obstetrics Monitoring system

“If [a midwife] can identify the issues, she knows where to ask. If someone has a strong backup from a specialist like an OBS-GYN [specializing in obstetrics and gynecology], then she will be more confident in going to the village and doing the examinations,” said Suwignjo.

A key goal is to make sure that women are able to access their checkups for free, whether at home or at the center, said Luh Ramiati, the head midwife at the center. And word-of-mouth within the community is important in this regard: People are recommending mothers to visit because of the tests and improved access to specialist care.

Ramiati noted that some of the attractions of the center now are the holistic care, a sense of community, and a more complete care process. After just eight months of use, the new facilities have helped increase the amount of women who attend their scheduled visits to more than 90 percent in the past month.

One of these new patients is Simanjuntak. Along with the trained staff, she found the sense of community appealing, particularly as she is from outside Papua and doesn’t know many people.

“The impact of coming to the center is that I know the progress of my baby,” said Simanjuntak. “This is my first-born, so I don’t have experience and a lot of knowledge. I believe the impact is the same with other expectant mothers: We are able to know the progress of our babies and we can exchange knowledge in the waiting room.”

Kurniati noted that the lack of community knowledge about the facilities is something that could be improved. “We’re sending out brochures about the ultrasound, usually through the heads of villages,” she said.

A sustainable future?

The project is in its first year, and the local government already wants to expand it from three to all 13 clinics in Jayapura. But the scope should be broadened, according to the mayor of Jayapura, Dr. Benhur Tomi Mano, whose key aim is to improve health and education.

A healthy pregnancy is important for attaining a healthier society, particularly in the context of Indonesia’s goal of achieving SDG 3, said Arif Dwi Darmanto, head of the local health department for Jayapura City. This means looking beyond the preliminary aims of the project.

“Regarding the partnership with the private sector, we would like the collaboration to be sustainable,” he said. “It is not necessarily about the price, but that it functions. This is what matters to us the most from the point of view of the district health department ... and the future of the project should include [tracking] nutrition and child health.”

Suwignjo noted that this long-term strategy is very much dependent on finding the right partners to implement the project, the number of primary care centers on board, and full buy-in from local stakeholders.

“The idea is very easy to sell, but the implementation has always been easier said than done … not only because of the geographic reach we need to achieve, but also how we implement and connect the dots with regards to all the stakeholders,” he said. “We need economies of scale.”

Innovation is not a silver bullet to any problem. But in a country of disperse and remote islands, perhaps digital technology could be key to improving access to care. The aims are set high, with the right stakeholders on board and with goals of not only helping to bring down such high maternal mortality figures but of helping track nutrition in the future generations of the country.

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Reporting/writing by Helen Morgan

Photography/video by Ore Huiying

Production by Naomi Mihara