DRAFT OF RECOMMENDATION As of March 31, 2017 Evidence Summit on Reducing Maternal and Neonatal Mortality in Indonesia 2016-2017 1
Alternative Policies Current Proposed Changes ANC Midwife, 4 times, 10 T (Doctor + Midwife), 8 times (WHO suggestion + mother s nutrition + monitor fetal development) Pregnant woman with comorbid disease: ANC always under doctor supervision Labor & Delivery Home, Private midwife, Maternal house/hospital, Puskesmas, Pustu, Poskesdes/Polindes Anywhere PONED-certified Puskesmas, PONED-certified maternal house (Competent personnel, open 24/7, etc), Every district have PONED-certified Puskesmas Maximum 30 minutes from PONEK HOSPITAL Referral Referral still not optimal On-line referral network (Ex: Sijari Emas) Personnel Training Training and rotation internship in PONEK Hospital Public Hospital Not all have PONEK ability ALL district public hospital should have PONEK ability Coverage JKN, Jampersal, BOK JKN, Jampersal, BOK: for all pregnant women 2
Health Facility providing ANC Institution Personnel Facility Strategic solution Regulation Primary Care Center/ (Fasilitas Kesehatan Tingkat Pertama): Puskesmas (complete with doctor + midwife + nurse) Clinic (complete with doctor + midwife + nurse) Doctor, Midwife, Nurse Outpatient All Primary Care Center should have doctor + midwife + nurse Loading First ANC should under doctor supervision KN by nurse/midwife, if problem detected, refer to doctor Increase ANC frequency to 8 times If comorbid disease present: next ANC selanjutnya should under doctor supervision If comorbid disease affecting fetal growth, communicate with PONED/FKTL PONEK ANC outside certified Primary Care Center, will not be covered by insurance (by JKN rules). 3
Health Facility providing Labor and Delivery Service Institution Time of service Personnel Facility Location Strategic Solution Regulation PONED-certified Primary Care Center 24 hours/day, 7 days/week Minimum 2 teams of PONED-trained doctor + midwife + nurse Delivery room and inpatient ward Reachable from PONEK hospital (< 30 minutes travel time) All inpatient Puskesmas turned into PONED Puskesmas, priority in location which reachable from PONEK Hospital Private midwives facilitated to join PONED-certified maternity house. All maternal and neonatal service covered by the government JKN regulation based on this policy Delivery in non-poned facility will not be covered by insurance Following the regulation will get several advantages: Free birth certificate, free family planning, etc. 4
Institution Time of service Personnel Facility Supporting Strategic Solution Regulation Referral Health Facility FKTL (Fasilitas Kesehatan Tingkat Lanjut) with PONEK ability: Hospital with PONEK ability Maternity Hospital with PONEK ability 24 hours/day, 7 days/week Trained OBGYN specialist, Pediatrician, Anesthesia, Doctor, midwife, nurse Operating Room and inpatient ward, including Blood Bank Loading 24 hour electricity (with generator), clean water guaranteed, good internet connection All district public hospitals should have PONEK ability Maternity Hospitals facilitated to have PONEK ability Reward & punishment system towards the institution performance Develop referral network that can monitor its patient whereabouts and the response anytime. Suggestion for referral system improvement: Referral system improvement is ongoing BPJS regulation should follow the referral standard 5
Health Facility Map: PONED PONEK HOSPITAL PONE D PONE RTK D PONEK Hospital PONE D RTK PONE D Bulin Good clinical and non-clinical communication system is needed in primary and referral Health facility. 6
Movement For Better Care Polindes Midwif e practice / Clinic Non-PONED / Maternal house PONED-certified Personnel Midwife Midwif Team: Team: Team: Hospital / Maternal Hospital with PONEK ability e Doctor, PONED trained PONEK-trained Midwife, Doctor, Midwife, Specialist: OBGYN, Nurse Nurse pediatric, anesthesia Works individually Works in team doctor, midwfe, Nurse Present ANC ANC ANC ANC ANC Suggested ANC ANC ANC Present Linakes Linakes Linakes Linakes Linakes Suggested Linakes Linakes 7
Preliminary Conclusion 1. 75% of maternal death happened in labor and 48-hours postpartum; 2. 58% of neonatal death happened in 48 hours after birth 3. Study suggest 70% death are preventable 4. Quality improvement in maternal and neonatal care is needed: Quality Continuum of care available 24/7 ANC and Labor & Delivery Service move from single to team- based provider (with minimally involve a physician). Delivery in PONED-certified primary care center Pregnant and in-labor woman with complication should be referred to PONEK Hospital. 8
Preliminary Conclusion 1. Comprehensive and supporting change of regulation (including JKN) need to take place. 2. Literature exploration by hand-searching is still needed to strengthen the evidence. 3. Support in literature contribution, good-practice/lessons learned evidence are needed from all stakeholder. 9