Reducing Maternal and Infant Mortality through High Risk Pregnancy Seekers
In Banyuwangi of Indonesia, one of the districts in East Java, 16 pregnant women died in 2015, as well as 28 babies. The largest contributing factor was a lack of data concerning the existence and whereabouts of women with high-risk pregnancies. So, in 2016, Sempu Public Healthcare Center launched an innovative solution using female vegetable sellers on motorbikes as high risk pregnancy seekers. As a result, the number of women and babies dying during and/or shortly after childbirth fell to zero.
The Initiative has two main objectives. First, to prevent maternal and infant mortality rate from rising in Sempu Sub-district, Banyuwangi, Indonesia. This is a critical situation because between 2012-2013m, Banyuwangi, a city with a population of 1.6 million, was threatened by high maternal and infant mortality rates. There were 48 cases of maternal death and 404 cases of infant death. This rate is higher than any other region in Indonesia. The highest number of deaths was in Sempu Sub-district, a population of 86,027: there were 16 cases of maternal death and 28 cases of children’s death.
Secondly, to educate women in rural areas about high-risk pregnancy. This is important because a third of Sempu Sub-district is jungle and mountains. There is an average of 1,000 pregnant women in a year. Their location can only be reached on foot so it is difficult for them to get access to healthcare services. As a result, they must rely on traditional birth attendants.
To achieve these objectives, in 2016 the Sempu Community Healthcare Center initiated an innovation by recruiting mobile female vegetable sellers to seek women with high-risk pregnancy. They were chosen because they sell their vegetables in rural communities and villages every day.
Using these local vegetable sellers as high risk-pregnancy seekers fulfilled at least three strategic criteria. Firstly, mobile vegetable sellers visit virtually every village between them every day, from just after dawn prayers until around 10 a.m. The total number of sellers was estimated to be in the hundreds so, by using these vegetable vendors, villages in the district could be reached and accessed more easily. This ultimately meant that public health facilities did not need to recruit additional staff to specifically to carry out this task.
Secondly, in keeping with local tradition, the primary customers of mobile vegetable sellers are housewives. They interact with each other every day, providing a well-established level of closeness and trust. As is the custom, information beyond the immediate task of buying and selling vegetables is often shared, including information about who is pregnant as well as their social, physical and mental condition. By providing the vegetable sellers with a little training on the key characteristics of high-risk pregnancies, they became reliable and accurate high risk-pregnancy seekers.
Thirdly, vegetable sellers in Banyuwangi possess fairly good knowledge and skill in using information technology (IT). Based on initial observations by members of the Banyuwangi Health Office’s Zero Maternal/Infant Mortality Team, almost all the vegetable vendors owned a mobile phone, while the majority were also familiar with smartphones. Their knowledge and experience of using mobile phones made the vendors all the more suitable to be high risk-pregnancy seekers.
A WhatsApp Group was employed to enable the high risk-pregnancy seekers to report any cases of high-risk pregnancies that they found, while an incentive scheme is also offered for those who successfully identify women with high-risk pregnancies.
The results of the programme have been quite significant. Before this intiative was launched, there was no programme to identify women with high-risk pregnancies in Banyuwangi. Now, a team of high risk-pregnancy hunters is in place that operates in three villages located within Puskesmas Sempu’s catchment area.
Between the launch of the programme in November 2016 and November 2019, high risk-pregnancy seekers successfully identified 117 women with high-risk pregnancies. Of this total, 98 women gave birth safely, while the remaining 19 women have yet to go into labour.
The information system at Sempu Healthcare Center is far more complete than before this programme was introduced. Now, the system has a map detailing the whereabouts of women with high-risk pregnancies, as well as complete data and referral reports on all pregnant women across the health centre’s working areas. Previously, data on women with high-risk pregnancies was only noted in midwife journals. In order to provide more detailed information, volunteer health workers conducted widespread first-stage checks to detect new pregnancies early on.
It should be noted that this innovation, which is barely three years into its implementation, does 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 the healthcare 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 East Java.
What Makes Your Project Innovative?
Reducing maternal and infant mortality through high risk pregnancy seekers is innovation in health sector as utilises female mobile vegetable sellers to support the midwives detecting high-risk pregnancy in villages is pioneer in this sector. This method is the first conducted in Indonesia and is a breakthrough in dealing with a limited number of midwives. It is effective and efficient because it is low cost but 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.
What is the current status of your innovation?
The innovative High Risk-Pregnancy Seekers programme continues to be implemented in the last three years. The uniqueness of this innovation 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 healthcare center.
Ongoing appreciation and support for the programme has also come from Indonesia’s Ministry of Health, which has awarded a new ambulance to the health centre to assist in its day-to-day operations. This help has been offered because the ministry rates Sempu Healthcare center as being highly innovative in initiating this programme to tackle and reduce maternal and infant mortality.
Collaborations & Partnerships
Sempu Public Healthcare Center created and launched the innovation. The center then works closely with female mobile vegetable sellers to implement the program. To optimise the implementation process, Sempu Public Healthcare Center collaborates with three village governments to allocate specific budget for the female mobile vegetable sellers as the high risk pregnancy seekers in these three remote areas. To promote the innovation, the center also works with local media and the midwife association.
Users, Stakeholders & Beneficiaries
High risk pregnant women who live in remote areas benefit from the existence of vegetable sellers. Their high risk pregnancy can be detected earlier. The initiative created a new volunteer system using mobile vegetable sellers for early detection of pregnancy in the toughest area. From them, the information then coordinated with the healthcare center, to the attending midwives and to medical specialists in the hospital if necessary. All these stakeholders contributed in reducing maternal death.
Results, Outcomes & Impacts
We conducted an internal evaluation. This initiative has an immediate outcome: the maternal and infant mortality rate was reduced to zero since the initiative was implemented, until November 2019. Before, the maternal mortality rate was at 16.
Infant mortality, from 28 deaths in 2012-2013, has also been reduced to zero (2016-2018) and two (2019).
Moreover, trimester visits for pregnant women to 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 works together and become responsible for the lives of pregnant women, especially for the high risk ones. This initiative, involving many to locate high-risk pregnant women early, should be replicated. Geographic and socio-economic conditions often keep them out of health workers’ radar, but women and infants’ lives are our priority and responsibility.
Challenges and Failures
First challenge, several points in three villages within the programme’s working areas that had no 3G/4G 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 at Puskesmas Sempu, who then entered the data onto the health clinic’s information system.
Second challenge, when the programme was first launched, there was also a concern about securing the necessary funding to cover the pregnancy seekers’ operational costs–especially those relating to the provision of their monthly mobile-phone credit. This challenge was solved, however, by including them as part of the Ministry’s Health Operational Assistance allocation.
Conditions for Success
Commitment and cooperation are the keys to success. The High Risk-Pregnancy Seekers initiative has succeeded due to the commitment and bureaucratic reform of the programme’s leader. Collaboration among all interested parties and key figures within the local community was also an essential ingredient.
Cross-sector cooperation is another extremely important factor. Close collaboration with subdistrict and village administrations helps to safeguard the sustainability of this innovation. Village administrations are prepared to allocate Rp 100,000 (US$10) per month to each of the pregnancy seekers. Initially, there was a lack of optimism about what could be achieved by embracing village administrations. However, thanks to the approach adopted by the head of Sempu Healthcare Center, who actively participated in Village Development Planning Meetings, they were moved to provide monthly contributions.
This innovation has been replicated in 44 community healthcare centers in Banyuwangi. In Indonesia, this initiative is studied through educational visits. More than 80 local governments and central agencies have visited to see firsthand the practical implementation and impacts from this innovation. International organizations that have seen it directly are the WHO, UNDP, and GIZ.
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 addition, this initiative was presented at the Asia-Pacific Regional Meeting, Open Government Partnership (OGP), 5-6 November 2018 in Seoul, South Korea.
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. The information provided by the pregnancy seekers merely paves the way; thereafter, it is the midwives and health volunteers who support the women throughout their pregnancies on up to their deliveries and during the initial post-natal period.
A positive work culture can become a catalyst for change. Sempu Public Healthcare Center, as a frontline agency alongside the local community, created and launched a novel way to find women with high-risk pregnancies. This new way was unique as it used the potential offered by mobile vegetable sellers. Moving on from this initiative, Banyuwangi’s District Head takes every opportunity to motivate local leaders to be creative when addressing public services by encouraging them to learn from Sempu Public Healthcare Center's innovative programme rather then waiting for orders from above.
Socially, the innovation was able to create strong caring network and was executed very fast. Everything has been done to protect the safety of pregnant women and their infants.
Economically, this initiative has been able to empower mobile vegetable sellers. By being volunteers for this initiative, they can reach the most remote area and interact with more local communities. Community Healthcare Center of Sempu also gives incentives of Rp 50,000 (USD 4.00) each month and healthcare protection as rewards for their contribution.
This initiative has been reinforced by Head of Sempu Sub-district Decree Number 445/143/KEP/429.591/2014 by establishing Sub-district and village management teams, headed directly by the Head of Sempu sub-district and consisting of various elements of community.