140 Saifuddin Med J Indones

Issues in training for Essential Maternal Health Care in Indonesia

Abdul Bari Saifuddin

Abstrak

Anglca Kematian lbu di Indonesia masih tinggi, yaitu sekitar 390 per 100.000 kelahiran hidup pada tahun 1994. Perkiraan AKIdari beberapa penehrtan sejak 1978-1994 menunjukkan penurunan yang lamban, walaupun telah dicanangkan bahwa pada akhirRepelin VI angla kematian ibu diharaplun dapat ,nenjadi 225 per 100.000 kelahiran hidup. Upaya penurunan AKI di Indonesia telah

banyak dilakukan. Diurailcan. tentang kerangka l<onseptual dari McCarthy dan Maine yang terdii atas determinan jauh, determinan

antara, dan keluaran. Keluaran meliputi proses kehannilan, komplilcasi kehamilan dan persalinan, dan kematian/disabilitas. Determinan

antara rneliputi status kesehatan, status reproduksi, al<ses pada pelayanan kesehatan, dan perilaht/pemanfaatan pelayanan kesehatan,

serta faktor-faktor yang tidak terduga. Determinan jauh melipurt stutus wanitct, status keluarga, dan status masyarakat. Pada bagian

terakhir ditinjau tentang peran pelatihan pada Gerakan Safe Motherhood, meliputi pendidil<an tenaga kesehatan dan pelntihnn laniutantenaga kesehatan. Peranan Jaingan Nasional Pelatihan Klinikyang dipeloport okh POGI yang memperkenalkan Pelartlnn BerdasarKompetensi dalam bidong Keluarga Berencana dan Kesehatan Reproduksi sangat berarti.

Abstract

The Matemal Mortality Ratio (MMR) in Indonesia remains high, i.e. approximately 390 per 100,000 live births. The esrtmated

MMR obtained from the studies from 1978 to 1994 suggests a sbw reduction, although it has been determined that by the end of FiveYear Plan VI, the MMR is expected to be reduced to 225 per 100,000 live births. The efforts to reduce the MMR in Indonesia have been

reasonably made. The conceptualframeworkfromMcCartlry andMaine, consisrtng of distant determinants, intermediate determinants,

and outcomc will be outlined. The outcome includes the process of pregnancy, complication of pregnancy and labor, and mortality/dis-ability. The intermediate determinants include health status, reproductive status, access to health services, health care behavior, and

unknown/unpredictedfactors. The distant determilwnts encompasses womm's status, family's status in community, and cotntnunity's

status. The last section of this paper reviews the role of the trainings in safe motherhood movement, covering the education of healthpersonnel and the subsequent continuing education. The role of the National Clinical Training Network initiated by POGI, which

introduces the Competency Based Training in Family Plnnning and Reproductive Health is very significant.

Keywords: Maternal Mornlity Ratio, comprehmsive framework, determinants, preservice training, in service training

The Maternal Mortality Rate, or more accurately theMaternal Mortality Ratio (MMR), is one of the in-dicators for assessing the success of health develop-ment. MMR is the key indicator that reflects maternalhealth status, particularly the mortality risk of pregnantwomen and for delivery. The target to be achieved inthe effort to reduce MMR in Indonesia has been estab-lished as a decrease to a MMR of 225 maternal deathsper 100,000live-births by the end of the 6th Five-YearDevelopment Plan (1994-1999) and 80 maternaldeaths per 100,000 live-births by the end ofthe SecondTwenty Five Year, Long-term Development Plan

Department of Obstetrics and. Gynecology, Faculty ofMedicine, University of Indonesia/Dr. Cipto MangunhtsutnoHospital, Jalcarta, Indonesia

(2015) respectively. The corresponding policies andaction plans to reduce maternal mortality have alsobeen established. These include the improvement ofintegrated management at both central and regionallevels, the equal provision ofhealth services, an enhan-cement of health service quality, an optimum increaseof basic service resources, the development of ap-propriate technology, the development of a manage-ment information system and community institutionactivities, social marketing, and operational researchfor improving the quality of

"ut" management.l

In accord with these policies, a variety of efforts havebeen initiated by both the government and the com-munity. Nevertheless, the MMR in Indonesia is still thehighest in the Southeast Asian Region. In addition,there exists a wide variation in maternal mortality rates

among provinces, even among the districts in any

Vol 6, No 3, July - September 1997

given province. However, unlike the MMR, in the caseof the infant mortality rate there has been a relativelysteep decline from 142 infant death per- 100,000 livebirth in 1968 to 57 per 100,000 in 1992.2

MMR IN INDONESIA

It is not easy to obtain accurate MMR data in develop-ing countries, particularly in Indonesia, primarily be-cause of the limitation of a vital registration system andthe lack of reliable data. Various attempts to obtain thisdata over a long period of time have been made inIndonesia. Unfortunately, the varying approachs usedfor data identification, analysis, and scope ofcoveragehas led to a great variety of MMR figures that requirevery careful interpretation.

Table 1 shows various estimations of MMR in In-donesia, based on a number of studies conducted from1978 to 1994.

1985 and 1986 Household and Health Survey (tHS)data, using an approach of retrospective data iden-tification and maternal mortality diagnosis with verbalautopsy, estimated Indonesian MMR at 450 maternaldeaths per 100,000 live-birthr.5 Ho*"u"r, the1985/1986 HHS sampled households in only sevenprovinces. Thus this estimated MMR figure can hardlybe thought of as a nationwide representation. Theretrospective approach is thought to be biased by atendency for underreporting to the extent that itprovides a lower estimation than what is actually thecase.

Table l. Estimation of MMR in Indonesia

Maternal Health Care Training Issues in Indonesia l4l

The 1992 HHS, covering 27 provinces of Indonesia,provided two estimations by means of two differentapproaches. Based on a retrospective calculation, theIndonesian maternal mortality rate was estimated to be404 maternal deaths per 100,000 live-births. Based ona prospective calculation (follow-up of pregnantwomen through the completion of the postpartumperiod), the MMR was estimared to be 455 per 1 00,000live-births.E

The Indonesian Demographic and Health Survey(IDHS) provided a national MMR esrimation of 390per 100,000 live-births for the perio d 1989-94, and 360per live-births for the other period of 1984-89 (sister-hood method, direct), and estimation of 326 per100,000 live-births for the period earlier then 1980(sisterhood, indirect).e It should be noted that thesisterhood method is essentially retrospective as well,so that there exists a possibility that the estimatedfigure is lower than the actual one, particularly for thepastperiods. In view ofthis "increasingtendency", theMMR based on the 1994 HHS may be interpreted assuggesting no changes in the maternal mortality rate.

If the similar retrospective approach of the 1985/1986HHS data is to be compared with that of the 1 992 HHS,MMR shows a declining tendency from 450 per100,000 live-births to 404 per live-birrhs. This figurewas, however, obtained from two different surveyswith a different coverage of provinces, and there maybe a probable sampling error in these approaches.

In view of the various estimations elucidated above, itmay be concluded that MMR in Indonesia is relatively

Area of study Est. MMR Type of study ReferenceYear

l2 teaching hospitals6 provinces7 provincesCentral Java, ruralWest Java, rural27 provinces

27 provinces

Record studyRetrospectiveRetrospectiveProspectiveSisterhood, indirectProspectiveRetrospectiveSisterhood, directSisterhood, directSisterhood, indirect

Chi l-chene3HHs. tgsôaHHS 1985sAgoestina and_ Soej oenoes6Budiarso et al /

HHS 19928HHS 19928IDHS** 1994e

370150450340490455404390360326

1978-8019801985-1986198719871991

1991

1989-941984-881981-82

* HHS = Households and Health Survey** IDHS = Indonesian Demographic and Health Survey

142 Saifuddin

very high and still a averages around 400 per 100,000live-binhs in the early 1990s.

EFFORTS TO REDUCE MMR IN INDONESIA

On June 29 1988, President of the Republic of In-donesia, Suharto, announced the Safe Motherhoodmovement and called on all sectors and parties tosupport this movement, the primary objective of whichwas to reduce MMR. A national meeting was sub-sequently held in November 1988 with the purpose ofenhancing the case and inter-sectoral cooperation be-tween the government and the community. In a furthereffort to establish national strategies and plans of ac-

tion to achieve the targeted reduction of MMR alreadyagreed upon, a nationwide assessment wâs conductedin 1991 by Department of Health, supported by TheUnited Nations Development Program and The WorldHealth Organization. The assessment report has beenpublishedln six volumes.lo(1)Assessment of Maternal Health Situation and

Health Services(2) Assessment of Socio-cultural Aspects

(3) Assessment of Midwifery education and Practices

(4) An Executive Summary of the Assessment and theRecommended National Strategies

(5) Recommended Plan of Action (1992-1996)(6) Summary of Recommended Provincial Strategies

Apart from the national assessment, it was necessaryto undertake studies leading to the provision ofinfor-mation on the actual efforts made in reducing MMR.The studies already conducted are generally descrip-tive and have not made use of a comprehensiveframework. A comprehensive framework in maternalnnortality was developed by McCarthy and Maine andconstitutes a further development of thoughts of thepreceding researches in safe motherhood and maternalmortality.ll McCarthy and Maine organized theirframework into three components of maternal mor-tality processes. The process that is the nearest tomaternal mortality is the sequence of events or outputscumulatively giving rise to disability or mortality. Thesequence of these events covers pregnancy, childbirth,and their related complications. A woman must bepregnant and experience some complication of preg-nancy or childbirth, or have a preexisting health prob-lem that is aggravated by pregnancy, before her deathcan be defined as a maternal death. Îhis sequence ofevents is directly affected by five intermediate deter-minants, i.e., health status, reproductive status, access

Med J Indones

to health services, health care behavior/use of healthservices and unknown or unpredicted factors.

On the other hand, various socio-cultural andeconomic factors (women's status in family/com-munity, family status in community, community'sstatus) constitute distant determinants that will affectMMR through those intermediate determinants. Withthis framework in mind, all the efforts aimed to reduceMMR must be undertaken through: (1) the preventionof possible conception; (2) the possible reduction ofpregnant women developing pregnancy or deliverycomplications, and (3) the improvement in the outputof pregnant women with complications.

Prodmate l)eterminants

With the success of Family Planning program, it canbe said that the current incidence of pregnancies inIndonesia is relatively lower than in the past. Thedecline in pregnancy incidence is evident from thedecrease of the Total Fertility Rate (TFR) from 5.61(period of 1967-70, according to Population Census of1,97 0) t92,85 (period of 1 9 9 I -9 4, accordin g to the 19 9 4IDHS).v The success of Family Planning program isalso reflected in the changes of various variables ofproximate determinants affecting a pregnant woman,e.g., the increasing use of contraceptives, first marriageage, and age at first sexual relationship. The 1994IDHS showed a decline in the proportion of mortalityof 15- 49 years old women as maternal mortality, andsuggested a decrease of the MMR of 15-49 years oldwomen from 42 maternal mortalities per 100,000women to 37 per 100,000.

Without any decline in the MMR, however, the ex-posure to the possible maternal mortality for womenalready pregnant remained unchanged. The leadingcauses of mortality remained the classic triad, i.e.,hemorrhage, gestosis, and sepsis, followed by anemia,prolonged labor and abortion.

Table2 shows the findings of a study by Agoestina andSoejoenoes6 in Central lava, whièh ioond th" Cu*"Fatality Rate to be 35Vo, l9%o, and ll.Vo respectivelyfor retentio placentae, hemorrhage, and sepsis. The1986 HHS, the 1992 HHS, and the 1995 HHS docu-mented the complications of delivery: hemorrhage,sepsis, and eclampsia, with almost constant prevalenceduring the last 8 years. The 1994IDHS reported a highincidence of pregnancy/delivery being effected bycomplications (24Vo), e.g., prolonged labor, hemor-rhage, infection, and eclampsia.Y

Vol 6, No 3, JuIy - September 1997

Distantdeterminants

'Women's stafus

in family and communityEducationOccupationIncomeSocial and legal autonomy

Family's statusin community

Family incomeLandEducation of othersOccupation of others

Community's stahrsAggregate wealthCommunity resources

(e.g. doctors, clinics,ambulances)

L

Maternal Health Care Training Issues in Indonesia r43

Intermediatedeterminan*

Health statusNutritional status

(anemia, height, weight)Infections and parasitic diseases

(malaria, hepatitis, tuberculosis)Other chronic conditions

(diabetes, hypertension)Prior history of pregnancy complications

Reproductive statusAgeParityMarital status

Access to health services- family planning- prenatal care- other primary care- emergency obstetric careRange of services available

Quality of careAccess to information about services

Health care behavior/use ofhealth servicesUse of family planningUse of prenatal careUse of modem care for labor and deliveryUse of harmful traditional practicesUse of illicit induced abortion

Outcomes

t.lltlrilrtllliri-ilt

lillltlllllr1ltlrl

Figure 1. Aframeworkfor analyzing the determinants of matemal mornlity and morbidity.lt

ComplicationHemorrhageInfectionPregnancy-induced

hypertensionObstructed laborRuptured uterus

144 Saifuddin

Table 2. Complication among a sample of pregnant womenand deliveries, Central Java, 1989

Med J Indones

increased from 8.6Vo (he 1986 HHS) to 9.8Vo (The1992 HHS).5'8

Reproductive Status

From the 1991 and 1994IDHSs, it is evident that thereis an increase in the first marriage age and in the firstdelivery age, the reduction of average childrendelivered, and the increasing distance of birth space.

Median age for first sexual relationship rose, and theprevalence ofteenager's delivery decreased. This pat-tern of reproduction has an effect on the reduction offertility and the number of pregnancy, and the changein composition of women delivering according to age

and child progression. The percentage of womendelivering first children rose, the percentage of womendelivering the fourth or more child decreased, the per-centage of safe delivery (2-3 children) remained un-changed. The percentage of women delivering at a safeage (20-34 years) also remained unchanged but theproportion of deliveries at an age below 20 years

lowered and at age 35 and higher tended to increase.

The changes in the reproductive pattern discussedabove do not significantly alter the composition ofpregnant women exposed to high risk maternal orinfant mortality. The percentage of women included inone of the groups of high risk deliveries does notsignificantly change: 67.2Vo for The 1991 IDHS and66.4Vo for The 1994IDHS respectively.e The percent-age of women to be included in two, or more, riskgroups also remain unchanged: 36Vo (The 1991 and1994IDHSs).e

Access to Health Services, Heolth Care Behavior/Utilization of Health Services

Access to health services can be viewed from suchfactors as locations of family planning services, prena-tal care, primary health care, or essential obstetric careservices provided for the community, the availableforms of services, quality of services, and access toinformation services. The government has madereasonable effort to ensure easy access to those ser-vices for the community primarily by developinghealth facilities, multiplying the availability of healthpersonnel and diversifying the kinds of services. TheRural Midwife Program, which aims at posting a mid-wife in every villages, started by the govemment in1992, may be a breakthrough towards these problems.

The extent of antenatal care coverage for pregnantwomen has, in point of fact, been broadened. During a

Complication Number CFRSample Death

RR 7o ARExposed

AnemiaYesNo

Emesis< 5 monthsNo

Hemorrhage< 5 months> 5 monthsNo

Rupture of membranePrematureNormal

InfectionYesNo

Retentio placentaeYesNo

LaborProlongedNormal

Toxemia

0,4 1,4

0,3 1,0

0 0,0n 19,1 122,2

23 0,2 1,0

3 9,7 30,7

47 0,3 1,0

270r4658

53489580

110t4t

14677

31

14897

12314805

3414894

190t4'138

11 4,1

39 0,3

13 10,6

3',7 0,2

1,8

98,2

35,8

64,2

0,70,8

98,3

0,298,8

0,8

99,2

0,299,8

1,3

98,7

2,O

0,697,4

2228

15,3

1,0

42,3

1,0

12,7

23,8

20,6

53,4

he-eclampsia 295Eclampsia 88No toxernia 14545

12 3s,3 138,3

3 8 0,3 1,0

8 2,7 11,6

8 9,1 38,934 0,2 1,0

5,8

25,4

0,7

t7,318,3

1 0,5 1,6

49 0,3 1,0

Total 14928 50

RR = CFR exposed/CFR not exposed

AR = p(RR-l)/tpGR-l)+llxsourie: Agoesiina and Soejoenoes6

Intermediate Determinants

Health Status

There has been a decline of anemia in pregnancy from74Vo (The 1985/86 HHS) to 63.5Vo (The 1992 HHS).There is still l3Vo of pregnant women with severe

anemia (Hb < 8 gVo).8 The 1992 HHS found nearly 57o

of pregnant women in Indonesia suffering from hyper-tension, with a higher incidence in rural areas than inurban areas (5.4Vo vs 3.9Vo).8

The pattern of the causes of general mortality in In-donesia has changed freq:1en1ly in accord with theepidemiologic transition. Degenerative diseases havebecome all the more evident, while infectious andparasitic diseases still play a part. TBC still has adominant place, and its contribution to death even

Vol 6, No 3, JuIy - September 1997

period of I erage was 80HHS)" but the percen to82Vo (The However, ofdelivery assistance has not changed. According to the1994 IDHS, only 36.57o of the delivery was assistedby health providers. The remaining were assisted bytraditional birth attendants (TBA). A great majority ofdeliveries took place at home (77Vo,Tlte l994IDHS).e

The IDHS 1994 demonstrates rhat high risk pregnantwomen have worse neonatal behavior than thosewithout risks. This also the case with pregnant womenwith lower level education and living in rural areas.The pelcentage of high risk pregnant women asdescribed above proved to remain unchanged.

Indirect Determinants

Although these determinants do not directly affectmaternal mortality, socio-cultural, economic,religious, and other factors must be taken into con-sideration and integrated into the interventions to beimplemented.

TIIE ROLE OF TRAINING IN SAF'E MOTIMR.HOOD INITIATIVES

Based on the above discussion, it may be concludedthat two main interventions can be implemented in theeffort to lower MMR:- To continue the efforts to prevent pregnancy by

means of increasing the availability and use ofmodern contraceptive services as a long-term solu-tion in reducing MMR.

- To promote the provision and coverage of essentialobstetric services in such a way that they are easilyaccessible to the communities as a more directapproach to lowering MMR.

In order to implement these interventions successfully,it is necessary to have health personnel (human resour-ces) in a sufficient number with adequate qualifica-tions. Health personnel resources currently providingobstetric services consist of consulting obstetricians/gynecologists, obstetricians/gynecologists, generalpractitioners, midwives, and traditional birth atten-dants.

Pre-service Training

At present, the number of consulting obstetricians/gynecologists is very limited and generally they serveas academic staff aT faculties of medicine.

Matemal Health Care Training Issues in Indonesia 145

Obstetricians and gynecologists (members of In-donesian Society of Obstetrics and Gynecology,POGI), at present, are approximately 800 in numberwith an uneven distribution. About 300 obstetriciansand gynecologists reside in Jakarta. The facility closestto the rural population where there might be anObstetricians and Gynecologist are district hospitals,although it should be made clear that not all districthospitals have obstetricians and gynecologists on staff.Currently, future obstetrician and gynecologists aretrained at nine educational institutions of higher learn-ing and now number 350 participants. The graduateobstetricians and gynecologists produced per yearrange between 60 and 80.

There are at present 32 faculties of medicine (compris-ing 15 faculties at state universities and li faculties atprivate universities) in Indonesia, producing anaverage of2000 graduates ofgeneral practitioners eachyear. Every graduate is obligated to undertake a man-datory assignment for the government for a period of1-3 years as non-permanent employee at healthcenters, which are divided into three categories: "Veryoutlying", "Outlying" and "Normal" health centers.During their education at medical faculties, it is hopedthat the graduates will obtain a capability in essentialobstetrics functions as outlined in the Core Curriculumof Faculty of Medicine specified by the Consortium ofHealth Sciences." However, as outlined in the Reportof MOIVUNDP/IVHO, itis statedthat "There is awidevariation in the uniformity of skills and technicalcapability among health personnel of the same profes-sional level, particulary those posted in health centersand District Hospitals in the management of pregnan-cy, delivery and post partum period".ls

It is also afactthatnearly 6O7o of the functions carriedout by health center physicians are administrativetasks, e.g. meetings with sub-district leaders and Min-istry of Health personnel, as well as providing reportsto the Ministry of Health, sub-district leaders, or theNational Family Planning Coordinating Board. Theclinical functions, particularly essential obstetrics, thatthe doctor undertakes is consequently limited, withmost of these functions carried out by midwives.

Paramedics providing these primary services are mid-wives. In addition, there are general nurses graduatedfrom nursing schools, nursing academy (a three-yeareducational program), and nursing diploma courses(those who complete an undergraduate diploma pro-gram in nursing). Midwives graduated from a numberof educational sources: (1) midwifery schools (these

t46 Saifuddin

schools 'were closed in 1980), (2) nursing and mid-wifery schools, (3) Midwifery Training Program-A,(4) Midwifery Training Program-B, and (5) MidwiferyTraining Program-C.

The Midwifery Training Program is situated in nursingschools. Currently, there exists 118 public nursingschools (this does not include Army nursing schools)and 54 private nursing schools located in 27 provinces.The Midwifery Training Program is established as anacceleration program to produce 54,000 Rural Mid-wives through 1996. Upon the completion of the ac-celeration program, The Midwifery Training Programwill be continued with the purpose of producing onlyabout 5,000 midwives each year as part of a "main-tenance" program. The midwives are coordinated byThe Indonesian Midwives Association (IBI), currentlywith 46,1_13 members in282 chapters throughout In-donesia.l5

Traditional Birth Attendants play a major role in preg-nancy and delivery assistance in Indonesia. Accordingto the 1994 IDHS, only 37Vo of the pregnancies wereassited by health personnel in Indonesia.e The 1991IDHS showed a percentage of 327o.This means thatmore than 60Vo of pregnancy was not assisted by healthpersonnel. It should be noted that there is no formaltraining required to be a traditional birth attendant andgenerally the skills of a traditional birth attendant ishanded down by means of infofmal apprenticeship. Atpresent, the number of traditional birth attendants isapproximately 70,000, and the majority have alreadygained some basic knowledge and skills such as find-ing and referring pregnant women, assisting withdelivery, postpartum care, and the treatment of highrisk newborns, "three clean" delivery assistance, homecare, postpartum mother and newborn care, nursingand health care by traditional birth attendant, reportsand services for pregnant women, delivery, postpar-tum, and newborn.

In-service Training

Today, the great majority of health personnel in In-donesia are those employed under the Ministry ofHealth, including Non- Permanent Employees. Duringthe period of employment, they are usually providedwith opportunity for in-service training, both throughthe Ministry of Health and through other governmentalinstitutions such as the National Family PlanningCoordinating Board (Division of Family PlanningTraining), as well as other professional organizations(Indonesian Medical Association, Indonesian Mid-

Med. J Indones

wives Association, Indonesian Association of SecureContraceptives, Indonesian Society of Obstetrics andGynecology, etc). Faculties of medicine are frequentlyengaged in launching continuing education in the formof training courses, refreshing courses, seminars, sym-posia and so forth.

Regretably, the vast majority of these trainings are notstandardized and coordinated; they are overlapping intheir contents and do not utilize "competency based"training method.

The existing courses held by the Ministry of Healthrange from manageriaUadministrative courses to basicclinical skill training, as well as public health courses.Through its Directorate General of Medical Services,the Ministry of Health has conducted a number ofcourses for health personnel destined to be posted tohospitals. The majority of these courses are held incooperation with teaching hospitals and professionalorganizations. Under the coordination of the Direc-torate of Public Health, these courses last for one tothree weeks and provide in-service training for ap-proximately 1,000 midwives each year. The plan is toincrease these midwife participants to 4,900 each year.

Since 1994, a Life Saving Skills (LSS) course, com-prising 10 modules, has been held_in 13 provinces bythe Directorate of Family Health.rÔ The 10 modules ofthis Life Saving Skills Course were adapted from theACNM and cover:- Introduction to Maternal Mortality- Antenatal Risk Assessment and Training- Monitoring Labor Progress- Episiotomies and Repair of Lacerations- Prevention of Treatment of Hemorrhage- Resuscitation- Prevention and Management of Sepsis- Hydration and Rehydration- Vacuum Extraction- Neonatal care

During 1994 and 1995, as many as 4,922 YillageMidwives were trained through this LSS Course. Anassessment of the effectiveness of this LSS trainingprogram was conducted in 1995 by Wibowo et al. in

East Java, South Sulawesi, and Westo.r7 A similar study was undertaken by. in 13 Indonesian provinces.ls thesl

studies arrived at the conclusion that the LSS trainingwas necessary but not quite effective towards enhanc-ing the skills of Village Midwives, particularly whenit was related to the effort to lower MMR. It is, there-

Vol 6, No 3, JuIy - September 1997

by which the competency of the trainees are ovaluatedboth at the beginning and at the end ofthe training, andso forth. Also, more attention should be focused at theadequacy of training sites in terms of equipment andtraining materials, trainers, staffing, case load avail-able for practice, and managemént of the training.

POGI's RoIe in Strengthening ReproductiveIlealth Training

Based on findings in the 7992 Jojnt IUD/1.{orplantTrainings Assessmentla by BKKBN, pOGI, andJHPIEGO, it was proposed to develop aunified, stand-ardized, and supervised national clinical training net-work. This network would be established from alreadyexisting, operating clinical training facilities; andwould concern itself initially with clinical training forNorplant, IUD, and Infection prevention (NIIp), aswell as providing a Refresher NIIp Training Course.Once a system for applying Competency Based Train-ing (CBT) to one area of reproductive health wasmastered by a core group of trainers, the intention is toexpand CBT through the National Clinical TrainingNetwork to other areas of reproductive health. Tofacilitate change throughout the clinical training net-work, POGI proposed implementation of a trainingsystem which created specific roles for and collabora-tive relationship among various levels/institutionswithin the network, including a NRC (NationalResource Center), PTCs (Provincial Training Centers),and DTCs (District Training Centers).

The primary role of the NRC is to guide the process ofdeveloping nationally agreed upon reproductive healthservice standards, developing training materials,preparing master expert trainers and clinical trainers,and develop a system of follow up and supervision thatshould be able to maintain the quality of the clinicaltraining network.

The PTCs' primary role is to standardize district leveltrainers in clinical skills, train district level trainers inclinical training skills, carry out clinical training fordoctors and midwives from the district level, and fol-iow up training at the district level.

Matemal Health Care Training Issues in Indonesia I47

The primary role of the DTCs is to carry out clinicaltraining for doctors and midwives from Health Centersand supervise service delivery,

To date much progress has been achieved in realizingthe unified and standardized national clinical trainingnetwork, with the focus initially on Family planning.Approximately 1,800 service providers have par-ticipated in the NIIP Refresher Course, more than 20expert trainers have proceeded through the AdvancedTraining Skills Course level, more than 70 clinicaltraines have been standardized and undergone a Clini-cal Training Skills course, and more than 1,800 serviceproviders have qualified and are practicing clinicalfamily planning based on the completion of a CBTcourss. A National Resource Document for FamilyPlanning Services has been completed for use as thestandardized resource forFamily Ptanning training andservices. A National Resource Center for ClinicalTraining, located in two sites (Jakarta and Surabaya),and 7 PTCs have been established. Other pTCs havebegun to take part in the two step process of servicedelivery standardization and clinical training skilltraining and practice.le

STJMMARY AND RECOMMENDATIONS .

From the above observations, it may be concluded thatthe MMR -- with a target toto 225 maternal deaths per

the end of the 6th Five YearDevelopment Plan -- will undoubtedly pose an enor-mous challenge.

The main interventions should be directed at the out-come of conception or pregnancy: reduction of the

complications andwhat complicationsregnancy (by meansinitiatives (essential

obstetric services) must be made in concert and in aprofessional way. For this reason, the adequate numberof health personnel and the optimalization of theirskills gained through both pre-service and in-servicetraining constitute an indispensable part in the strategy.

ing network in Family Plan-PTCs and DTÇS, developedbe beneficial.le It is hopedso be used for the clinical

training in essential obstetrics, through both pre-ser-vice and in-service training. The health personnel as-

148 Saifuddin

sociated with the outcome (proximate determinants),particularly physicians and midwives, will be able tocome away with better skills from this training. In viewof the breadth of coverage, a pilot project for EssentialObstetrics at the level of NRC may be necessary, withseveral PTCs to implement an Essential Obstetricsclinical training project at an initial stage.

Through POGI the obstetricians and gynecologists atthe district level, whose number is very limited, shouldbe encouraged to broaden their tasks to include rolessuch as resource person and initiator in developingimproved system of maternal health services at theirlocations. Also the delegation of authority fromobstetricians and gynecologists to general prac-titioners and midwives in the front-line will providetdlutionr to the existing geographical and time con-trarnt problems, particulu.ty i" emergency situations.Health centers should be able to carry out their func-tions in essential obstetrics, as recommended byWHO.20 On the other hand, the health providers whohave proved themselves to be capable to carry out theirtasks should receive a reward in the form of credits thatcan be caulculated in pursuing a higher or continuingeducation.

The utilization of appropriate and relatively new com-puter assisted training tools, such as Repro System,will be of benefit in improving the transfer ofknowledge, updating trainers, and strengthen plan-ning. Trainees can come to the clinical training site forthe purpose of enhancing their clinical skills since thenecessary new knowledge has already been acquiredthrough a computer assisted learning program likeModCal, whichis alsopartof Repro System. Usingthisapproach, a gteat deal of time and money can be savedfor basic training activities.

Another factor worth considering is a reorientation ofthe physician's tasks at health centers. This reorienta-tion could be accomplished by putting more emphasison clinical functions that include essential obstetrics.Administrative and other non-medical functionsshould be gradually transfered to other competenthealth personnel, such as public health graduates thathave hitherto been produced in a fair number from fivefaculties ofpublic health in Indonesia.

REFERENCES

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