Professional Assistance during Birth and Maternal Mortality in Two Indonesian districts/Assistance Professionnelle Pendant la Naissance et Mortalite Maternelle Dans Deux Districts indonesiens/Atencion Profesional En El Parto Y Mortalidad Materna En Dos Distritos De Indonesia

Introduction The fifth Millennium Development Goal (MDG 5) is to reduce the maternal mortality ratio worldwide by 75% between 1990 and 2015.1 An essential strategy for achieving MDG 5 is to ensure that all births are managed by skilled health professionals. This strategy requires high population coverage and an enabling environment, including 24-hour access to effective emergency obstetric care. (2,3) Ecological studies have shown an inverse correlation between the number of health professionals per unit of population and the proportion of births attended by a health professional on the one hand, and maternal mortality on the other. (4-6) However, causal inferences cannot be robustly drawn. (2) Few studies have assessed whether the percentage of births assisted by a health professional within a population correlates with maternal mortality, (2,7) and even fewer studies have checked for a correlation between an individual woman's use of a health professional at birth and her risk of maternal death. (2,8) Thus, the size of the effect that a given strategy to promote skilled birth attendance could have on maternal mortality is unclear. (3) Indonesia is one of the few countries that have implemented initiatives to provide midwifery care in the community. In 1989, the Indonesian Government launched a safe motherhood programme that aimed to assign a midwife to every village. (9) Within seven years, more than 54 000 midwives had been posted, (10) and the proportion of births managed by a midwife or other health professional had nearly doubled (from 35% in the late 1980s to 69% in 2000). (11) In response to the economic crisis in 1997, (12) the government introduced a social safety net programme that exempts the poor from paying health service fees. In 2005, a new health insurance scheme called ASKESKIN (asuransi kesehatan untuk keluarga miskin or health insurance for the poor) (13) made the poorest families eligible for fee exemption for routine and emergency care. Under ASKESKIN, midwives are paid to manage deliveries, either in their own home or in the pregnant woman's home. In this paper we evaluate Indonesia's safe motherhood programme by examining whether differences in the availability and use of midwives and other health professionals at birth can explain differences in the risk of maternal mortality in two districts in West Java. (14,15) Methods Safe motherhood programme and study population As part of an international research initiative known as the Initiative for Maternal Mortality Programme Assessment (Immpact), (16) we measured maternal mortality, assessed the provision of midwifery care, and determined the levels of uptake of professional delivery care in the Serang and Pandeglang districts of Banten Province, Java, Indonesia. Serang is 72 km from Jakarta, the capital of Indonesia, and moderately Urbanised, with three hospitals and 36 health centres for its 1.8 million people. Pandeglang, more remote, has one district hospital and 30 health centres for its 1.1 million people. Serang and Pandeglang districts have 55 and 23 urban villages and 318 and 312 rural villages, respectively. In these two districts, the uptake of professional care at birth is lower than the national average. (15) Data sources Informant-based identification of maternal deaths A double informant-based approach based on Maternal Deaths from Informants (MADE-IN) and Maternal Death Follow-on Review (MADE-FOR) (17) was used to identify all maternal deaths that occurred in the two study districts between January 2004 and December 2005. MADE-IN uses existing village administrative systems to collect information about women's deaths. Village informants held "listing meetings" during which they listed the details of deaths in village women 15 to 49 years of age that occurred over the previous 2 years. The informants were health post volunteers (kaders) and unpaid village officials (rukun tetangga or RT heads), both of which were used in all urban villages and in a random sample of 78 rural villages. …