A baby was sleeping peacefully under a mosquito net in a North Jakarta home. His mother is a solidly middle class college graduate, but she opted for a midwife to deliver her second child, as with her first. The midwife in both instances had 26 years of experience under her belt. Sporting stylish black-framed glasses and a deep purple scarf, 56 year old Bratatin is a well respected figure in this neighborhood.
Mrs. Bratatin represents the local chapter of Bidan Delima, a program that provides accreditation to private midwives to ensure quality. She is one of more than 9000 Bidan Delima midwives in the country—the franchise is active in 21 of 33 provinces.
Need to reduce Indonesia’s maternal mortality rate
Indonesia’s economy grew last year at its fastest pace in 15 years, with a GDP expected to top $1 trillion USD this year. Squint your eyes in Central Jakarta and you could be in Hong Kong, with towering shopping malls and Louis Vuitton boutiques.
Today, less than 6% of the population subsists on less than $1 per day, compared to 20% of the population in 1990. The country has a literacy rate above 99% and near universal enrollment in primary education. Children are much more likely to survive to their fifth birthday.
Yet maternal mortality rates lag far behind the country’s Southeast Asian neighbors. Indonesia’s National Development Planning Agency reported in 2010 that "hard work is needed to meet the target of 102 [deaths] per 100,000 births."
In response, the government recently launched a health insurance program covering in-hospital deliveries for all women and complementing other government insurance programs available to low-income families. Yet, perhaps because more women are now delivering in hospitals and being counted, the reported mortality rate seems to have actually increased—while this is likely due to previous underreporting, it indicates a serious need to accelerate progress.
Midwives save lives
The best way to save women’s lives in birth is to ensure that they have a skilled health provider at their side. Nationwide, more women are giving birth in hospital, but it varies dramatically from region to region. In Bali, 90 % of women give birth in facilities, while in Sulawesi Tenggara, only 8.4% of women give birth in facilities.
Many lack access to facilities. Particularly in remote areas of this archipelagic nation, women worry about the cost of transportation as well as road quality, as a recent study reported about West Java. Yet even on remote islands women may have access to midwives. There are more than 60,000 midwives in Indonesia, half of them with private practices.
The Indonesian Midwives Association (IMA) launched Bidan Delima (literally, “midwife pomegranate”) with support from USAID in 2003 to set and ensure adherence to standards for safe pregnancy and delivery practices among private midwives practitioners in Indonesia.
Midwives pay a membership fee of IDR 400,000 (USD 44) to join Bidan Delima, with an annual renewal fee of IDR 250.000 (USD 28). District facilitators recruiting new members administer a test assessing prospective members’ knowledge about midwifery practice standards—they must score 100%! Later, district facilitators conduct monitoring and evaluation to assess the midwives compliance on the standards.
Expanding the franchise
The USAID grant paid for branded promotional materials, like a checklist distributed at clinics that listed the top 10 things a woman should know about pregnancy. Since the end of the grant, the IMA has launched new initiatives to grow Bidan Delima’s network.
A new partnership with the Indonesian telecommunications company Telkom has produced a simple phone programmed with useful information for midwives, with special Bidan Delima features. This mobile application allows midwives who rarely access internet to receive updated information from Bidan Delima and IMA about opportunities like upcoming training. Midwives can purchase the phones for about $58 USD, with the proceeds split between Telkom and IMA.
And a new partnership with ACA Insurance will provide midwives with the opportunity to sell a simple, inexpensive insurance card covering families against costs of treating dengue fever. Jakub Nugraha of ACA told us that the Dengue Fever Insurance card costing $1 USD covers “1 million rups,” or up to $100, and the insurance is good for three months. Families can also purchase a $5 USD different card that covers up to $200 of claims and lasts for one year. Dengue is endemic to 70% of Indonesia, and dengue and the hemorrhagic fever it causes is a main cause of hospitalization and death among children. The insurance could be useful to families, and the partnership could provide Bidan Delima-accredited midwives with more to offer clients over their competitors.
Midwives refer pregnant women to see specialists as soon as they discover abnormalities that will affect labor. But it is sometimes difficult to convince women and their families to go to facilities. There are financial and geographic barriers—poor roads, vast distances to specialty care, and transportation costs.
If it is necessary, midwives advise women to seek care in facilities as soon as possible. In emergencies, they often help to find women transportation to specialty care. And now midwives help pregnant mothers obtain government sponsored delivery insurance cards, called jampersal, so they can obtain free delivery care when they arrive at qualified health facilities.
A relationship built of trust
It was apparent during our visit that Bidan Delima midwives are not just health providers but trusted community members and friends who can be counted on to provide good quality advice and services.
In North Jakarta, Mrs. Bratatin sat comfortably with the pajama-wearing mother of two in her living room as they chatted about the dengue fever insurance cards. Then she walked back to the midwife center, waving at neighbors along the narrow streets.