Midwives and Maternal Mortality: How Effective Has Indonesia’s Village Midwife Program Been?

1. Midwives and Maternal Mortality:How Effective Has Indonesia’s Village Midwife Program Been? ShailenderSwaminathan (Brown) Tomoya Matsumoto (GRIPS) Jeffrey B. Nugent (USC) March 2010

2. I. Motivation • Millennium Development Goal (MDG5) is to reduce the maternal mortality ratio (MMR) by three quarters between 1990 and 2015. • Decline in mortality among adults may be more important for development than among children • Given budget constraints and difficulty of reducing MMR, quest for cost-effective measures for doing so is important • What program(s) to select?

3. Midwives Programs Commonly Identified as Likely Candidate • Historical Precedents • Sweden in Late 19th Century MMR reduced substantially as Midwives spread throughout country • Sri Lanka 1946-60 • Malaysia 1960-1985 with 75% reduction in MMR • Methodological Shortcomings: No controls for other factors changing concurrently despite the fact that many factors were changing simultaneously • Consensus Recommendations of International Experts and Organizations like WHO • The Lancet Maternal Survival Series Steering Group 2006 “Maternal Survival 2: Strategies for Reducing Maternal Mortality: Getting on with What Works” • Is This priority justified?

4. Obstacles to Careful Study and Shortcomings in Existing Studies Absence of reliable reports on MMRs since majority of deliveries are at home Those programs which have been studied have had inadequate controls Absence of useful randomized trials

5. Dearth of Randomized Trials on Determinants of MMR • Those randomized trials that do exist on MMRs • Examine Specific Drugs Effectiveness, other health conditions • Most relevant study: a Pakistani study on the effectiveness of giving short-term training to traditional midwives (as opposed to training new midwives for a longer period as in the Indonesian case). • Result: by itself at least, this program did not significantly reduce maternal mortality in Pakistan (Jokhio et al, 2005).

6. II. Indonesia Village Midwife Program • Motive: In mid 1980s Indonesia’s MMR >400 per 100,000 live births • VMP Established in 1989 to train midwives • 1 year of training (generally on top of several years of nursing) • Primarily deployed only beginning in 1993 • By 1998 54,000 midwives deployed to underserved rural villages • Midwives per capita increased more that 10 fold, from 0.2 per 1000 to 2.6 per 1000 between 1990 and 1998.

7. Features of Indonesia’s Program

8. Known for low cost methods: Burning the Umbilical Cord

9. Although Midwives allocated to underserved areas, Shortcomings Noted • Hatt et al (2007) : Did not reduce urban-rural gap in access to emergency care, such as to Caesarian sections and even widened it • Makowiecka et al (2008) VMW services became less equitable between less remote and more remote areas • Early studies comparing 1989 with 1994 had shown little MMRate reduction

10. Data • Demographic and Health Surveys in Indonesia of 1994, 1997 and 2000: Data on Maternal Deaths MMRate = Maternal deaths at t /100K Women aged 15-49 Sisterhood Method (WHO 2004) Females asked to identify female siblings born of same mother, living or dead. If dead, asked to identify cause of death, if during pregnancy or within 2 mos. Post-partum. This done at national, rural, urban and province levels

11. Explanatory Variables Fraction of districts with village midwife (VMP) at national, rural, urban, province levels since 1975 using data from IFLS 1993, 1997, 2000. * Other Controls: Age of woman, income, education of mother, time, alternative service provision

12. Regression Model MMRater-ut= α0+ α1time +α2VMP+ α3Xr-u t +ut(1) Midwife r-ut = β0 +β1time+ β2VMP + β3Xr-u t +v t (2) • T = 1975, 1976,………….2000 • α 2 and β2 represent difference in effects of VMP between rural and urban areas where VMP =0 before 1993 (diff in diff) • If other factors constant between pre and post program periods, these effects could be causal,

13. RRRRURAL RR

16. Results of Table 1 • -12.1 for the VMW –Rural Dummy interaction term implies that the difference in MMRates between rural and urban areas was 12.1 lower post-program than pre-program. Pre-program it was 21 percentage points higher in rural areas representing almost 60% of the differential. • Next (Table 2) a more detailed look at the difference in means before and after and difference in trends

18. Results of Table 2 Almost 11 percentage point reduction in means of w/o adjusting for midwife availability (col. 2) But after controlling for midwife availability, only a 3% fall (col. 4) Hence over 70% of the fall in rates can be explained by VMW availability

19. Province level Analysis Explanatory variables: linear time trend, fraction of districts with VMW, province level fixed effect Table 2 shows that VMW availability explains 6% of intra province changes in MMRate. Use this to predict the MMRates by province Figure 3

22. Compare Figures 3 and 2 For the provinces that are most substantially rural the drops are very sharp whereas the most urban least affected by the VMP, there is virtually no decline.

24. Robustness Other access differentials between rural and urban areas Changing the date of startup of the program

25. Conclusions Indonesia has made significant progress to MDG Goal for 2015 But by no means enough to achieve it Despite small numbers of data points available , most of the decline achieved seems to be due to VMP Possible areas for improvement over time Possible areas for future research

26. Benefits Costs of VMP Much could be done to improve it But, even if the payoff in MMRate is deemed insufficient to justify it, because of other benefits that have been documented, such as on birth weights, child health, increasing BMI of women, increasing child spacing and reducing fertility rates, overall benefits might well outweigh the costs.

27. Reasons Offered for the Disappointing Results of the VMP • Low quality of training • Lack of financing and access to hospitals when needed • Lack of sustainability: urban born women not happy about having to live in villages w/o many amenities • Insufficient incentives for high quality service delivery • Shortages of materials and equipment at local level • Numerous transport and communications problems locally • Conclusion: Despite its promise, Not obvious that the program has had significant effects on MMR

28. Other Changes Affecting Results • 1999 Decentralization Program Failures: local governments revenue constrained, hence often cannot pay the midwives and buy the supplies • 1997-8 financial crisis: loss of income, inflation, supply shortages weakening provisions at local level • Gradual increase in malaria which would weaken pregnant women and make them more vulnerable to infection, death during pregnancy and childbirth

29. Shortcomings and Extensions • MMR data not reliable: Could use other indicators excessive bleeding at birth, prompt referral of complicated cases. • Use of still other sources of midwife availability. How sensitive would results be to such alternatives. • Experience as of 2000 quite short, future rounds of IFLS should provide more reliable estimates • How much substitution among providers has there been? • Has the quality of care by other providers been affected by presence of VMW?