A REACHOUT update from Indonesia

By Kate Hawkins

Main messages
The first Quality Improvement (QI) cycle will focus on strengthening the partnership between Village Midwives, Kaders, and Traditional Birth Attendants (TBAs)
The intended outcome of this work is increased referrals to health facility for delivery
Through the health promotion intervention the communication and advocacy skills of Village Midwives, Kaders and TBAs will be strengthened
There will be a focus on community engagement including male involvement
Interdisciplinary and multi-methods research will be applied to measure the outcomes of the QI cycle
The QI cycle in Indonesia is focussed on health promotion, partnership, and community engagement. This will be supported by interventions to strengthen the supervision of community health workers. Village Midwives in four villages in Cianjur (more than 200 community health workers) will be trained in health promotion and provided with counselling cards that help them explain the danger signs in pregnancy and childbirth and importance of childbirth in health facilities. In health promotion we will train village midwives and kaders in 4 villages in Cianjur. This is more than 200 CHWs. The Village Midwives and kaders will use home visits and appointments in the community intergrated health posts (Posyandu) to talk about this information. This also explains when referral should happen.

The second intervention is focused on partnership and community intervention. Close-to-community providers will be encouraged to stimulate broader stakeholder engagement on the topic of maternal health. Community forums only happen about once a year in some of the settings REACHOUT are working in. This means the barriers and the issues don’t get discussed. The team will encourage stakeholders to come together more often in partnership with village leaders.

The midwife coordinators – who oversee the village midwives – will be provided training related to supportive supervision.

Various methods will be employed to measure the impact of the intervention. Village Midwives will be observed at the Posyandu. The team will also conduct exit interviews with mothers who attended sessions to get a sense of their knowledge the delivery of information. To measure the partnership and community engagement element of the work the team will track the number of women who go to the facility for delivery as a result of advice from the Village Midwives, Kaders and TBAs and women’s perceptions of the importance of institutional delivery. They will track the number of home deliveries to see whether the TBA or Village Midwives are in attendance. For the community engagement strand of work we will monitor the number of meetings in community. To measure the effects of supportive supervision training the close-to-community providers will be asked to complete a motivation questionnaire. For health promotion the team will use numbers of people who deliver in a facility and will track the perceptions of women on the importance of delivering in a health facility. Whilst there is a policy on the relationship between the TBA and Village Midwife REACHOUT are innovating by bringing the Kaders in to this engagement. To stimulate support at the community level they will encourage more frequent community forums which are currently lacking. The team hope to improve the Village Midwife and Kader negotiation and advocacy skills.

One challenge is that there is still a great deal of trust in TBAs and preference for them even though they are forbidden from conducting deliveries at home by government policy. The REACHOUT team also believe that it is important to engage male partners as they are not very involved in decision making around delivery. This will require support from health and non-health stakeholders.