Promoting Midwife use in Shaman-predominant settings – Si Midun Ke Faskes

The Health Office launched a partnership Strategy program to promote the uptake of midwives and health facilities, establishing a synergy between Shamans and Village Midwives. The results of this problem have cut by more than half the maternal mortality rate during child birth.

Innovation Summary

Innovation Overview

The Problem

The death rate of women during pregnancy or for 42 days of pregnancy termination in Indonesia was very high. This is indicated by the high Maternal Mortality Rate ( MMR). MMR is the number of women deaths during pregnancy or for 42 days of pregnancy termination regardless duration and place of birth, that was caused by the pregnancy or the management and it was not caused by others such as an accident or falls per 100.000 live births.

Based on Indonesia demographic and Health survey ( IHDS ) in 2012, Maternal Mortality Rate (MMR) in Indonesia was around 359 per 100.000 live births. It was slightly decreased when compared with IHDS in 1999, that was 390 per 100.000 live births. It did not reach the the fifth Millennium Development Goals target, that was reducing MMR to be less than 70 per live births.

There is a more complicated experience in Hulu Sungai Selatan Regency, South Kalimantan in overcoming the high rate of women death in pregnancy and childbirths was marked by the high of MMR. MMR in 2012 and 2013 was 301 per 100.000 live births. And 262,2 per 100.000 live births. Hulu Sungai Selatan Regency are mountains that extend from the east to the south and alluvial lowlands are from the west to the north, which are swampy areas.

One of the main factors of the high rate of MMR was the childbirth helped traditionally at home by shamans, who were not trained and they ignored the health standard, so it caused of bleeding, high risk pregnancy, sepsis, and eclampsia that were difficult to be controlled and saved. The beliefs of the people Hulu Sungai Selatan regency to the shamans were very high, especially the middle to the lower economic families who live in the rural areas that are very difficult to reach public health facilities.

There are many factors believing shaman, they are:

Firstly, experience. Shamans are well known from generation to generation, they naturally helped delivery by simply cutting the umbilical cord without cutting, operating and sewing.

Secondly, tradition and customary, they helped to the pregnancy ceremonies, birth and post-birth, which are important heredity inherited by ancestors.

Thirdly, education and socioeconomic, the people’s choice on shaman to help delivering because the low cost, it is cheaper than by midwives’ help and they ignored hygiene and safety.

The number of shamans in HSS regency is about 120 shamans, there are 15% are in mountainous areas and 40 % are in swampy area. Although the midwives have been assigned to every villages, it has not been able to dispel the people trust towards shaman. Despite having adequate certification and training, midwives is considered too young, lack of experience in assisting childbirth, and has no knowledge in performing traditional ceremonies.

The Solution

The Partnership Strategy between Shamans and Midwives taking Maternity to Health Facility includes all parties without eliminating the role of each party. This program was managed to create a collaboration between Shaman as an experienced person with local wisdom, and respected by community but never got medical education and midwifery training, while midwives who have received medical education and midwifery training but less trusted by the community because considered young and lack of experience. Then, with this collaboration, the community has more trust in midwives with shamans’ support and choose to do delivery in health facilities.

Another initiative was the scholarship program for local girls, especially in mountainous and swamp areas, which were 12 girls studying to become midwives and after finishing their education the would be assigned in their own villages. It aimed to divert the role of shamans wisely and gradually and the shaman should be appreciated their existence by assisting the midwife in carrying out the duty to help a deliver in the health facility. This initiative effectively overcame strong local cultural traditions. Conventional culture, customs, heredity and traditions in helping of birth delivered by a shaman because of trust. Shamans were invited to participate in a mutually beneficial partnership of midwives and shaman, the initiative run successfully. Their partnership made Maternal Mortality Rate (MMR). And it was also supported by giving a scholarship program for local girls who lived mountainous and swamps areas for midwifery education and assigned them in their own village. Their similarity of origin and kinship relationships made this partnership strong. They worked together to help the delivery at the health facility keep mother and her baby from dying.

Innovation Description

What is the current status of your innovation?

Partnership Strategy between Shamans and Midwives taking Maternity to Health Facility (Si Midun To Faskes) was initiated by the Government of Hulu Sungai Selatan regency through Health Office of Hulu Sungai Selatan Regency. Then in the implementation phase of Health Office of Hulu Sungai Selatan Regency through all Public Health Centers and Midwife Networks to socialize and counseling personally to shamans regularly to establish cooperation between shamans and Midwives. so, pregnant women could utilize medical personnel and health facilities in labor process.

Innovation Development

Collaborations & Partnerships

The Partnership between shamans and midwives was done by Hulu Sungai Selatan regency through the health office run many stages. Starting from identifying problems, coaching and personal approach towards shamans routinely in the public health center by inviting Shamans at work- public health area.

"Si Midun To Faskes" showed the result as frequent coaching that has been done since 2012 and financial support giving incentives to shamans who took maternity to health facilities. This partnership became very important in an attempt to reduce the maternal mortality rate (MMR) in Hulu Sungai selatan Regency. The collaboration between the two elements into a mutually beneficial collaboration which was characterized by increased delivery in health facilities.

Users, Stakeholders & Beneficiaries

Stakeholders involved in the implementation between midwife and shaman's partnership were the health office of Hulu Sungai Selatan Regency, Head of public health Centers, midwives, shamans and Head of Village, Family Welfare Guidance (PKK ), public and religious figures, The budget for implementing the Midwife- Shaman Partnership in Hulu Sungai Selatan was from the local government budget.

Innovation Reflections

Results, Outcomes & Impacts

The fatality rate in this region has dropped from 12 birthing-related deaths per year to 5.

The data of delivery helped by shamans since 2012 to 2016 is as follows: 1. Year 2012: 124 births by shaman from 4015 births. 2. Year 2013: 55 births by the shaman from 3327 births. 3. Year 2014: 93 births by shaman from 3931 births. 4. Year 2015: 69 births by shaman from 3677 births. 5. Year 2016: 29 births.by a shaman from 3667 births It was shown that the MMR significantly reduced in the year 2012 to 2016, since this program had run.The following data that shown the significantly decreased since 2012 to 2016. 1. Year 2012: 301 per 100,000 Live Births 2. Year 2013: 262.2 per 100,000 Live Births 3. Year 2014: 208.4 per 100,000 Live Births 4. Year 2015: 136.3 per 100,000 Live Births 5. Year 2016: 108.8 per 100,000 Live Births Increased delivery in health facilities by midwives.

The previous delivery help was at home and was done by shaman with high risk of childbirth, then now was done in the health facility and helped by the midwife as a competent health worker. Based on data,delivery helped by shaman tended to decrease in the last 5 years although it has increased again in 2014.

It was in line with government regulations requiring that the delivery help be done by medical personnel at health facilities. It can be seen from the output that delivery help in health facilities more done than at home. Empowerment and commitment between midwives and shaman signed by the Village Head.

At present, 96 Village Health Posts have been built. 12 local midwives from the scholarship program have been assigned in their own villages. The scholarship program for local girls for midwifery education and assigned them in their own village made the partnership between midwives and shaman increase due to the similarity of origin and kinship relationships.

Challenges and Failures

The rejection and the first resistance was done by the villagers. The tradition of delivery helped by shaman is a hereditary tradition that has been running for hundreds of years before modern medicine was introduced in Indonesia. This is a tradition that has been firmly planted and very difficult to change so many did not dare to break it. Strong cultural values and community have not been able to change the tradition of switching to midwives, especially for people in mountain areas.

Replication

In terms of finance, this program is very feasible and proven to be run well for five years. The need for financial resources was high at the time of initial initiation in the form of socialization of the Partnership Strategy Program, development of Village Health Post and provision of ambulance aid.

In socioeconomic terms, the program can be run continuously because of the transparent cost of health services related to pregnancy and childbirth and it is free for women who has national health insurance.

In terms of culture,this program provides a place for local wisdom without ignoring the culture and traditional ceremonies and role of shamans who keep accompanying pregnant women during the process of pregnancy to post birth.

In terms of institutions and regulations, the program has been implemented with the regulations starting from the Regulation of the Minister of Health.

Lessons Learned

1. The empowerment of women is very important for the community, as they are the people who build the family life in Indonesia.

2. The program runs by establishing cooperation and consistency of each party from the Local Government

3. The partnership between Shamans and midwives encourages delivery in health facilities and it changes the paradigm of people towards healthier childbirth without eliminating cultural traditions and strong local wisdom and inherits from generation to generation

4. The Partnership Strategy Program comes with an applicable,sustainable and replicable design for every Local Government that has the same characteristics.

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