Small fixes, big changes
Health workers drive initiatives to reduce maternal and newborn deaths in West Lombok
From electricity cuts to a scarcity of doctors, the hurdles facing Midwife Desak to deliver care for her patients in West Lombok since the 1990s have been beyond her ability to fix. At times, the consequences have been drastic.
“I still vividly remember the bed she occupied,” Desak recalled, pointing to a maternal ward at her workplace of Patut Patuh Patju Hospital in West Nusa Tenggara (NTB).
She was referring to a pregnant woman who succumbed to death one night in 2018. Desak had stayed by her bed the whole night, and deeply mourned her loss of life. The woman could have been saved if her family accepted the advice to refer her to a bigger hospital.
Unwilling to witness more preventable deaths of mothers or their newborns, Desak began to lead a new team in the hospital’s maternal unit in 2019. Their task was to identify problems with the quality of services provided by the unit and resolve them immediately. A similar team was also formed in the hospital’s neonatal unit.
The teams were not well resourced, however, leading them to zero in on what could be achieved without major financial investment. “Barely any cost is needed to improve health staff’s compliance [to standard care], unlike improving infrastructure. What we need is eagerness and motivation,” Desak said.
While a health system overhaul is underway, any immediate improvement is crucial for a province like NTB, which has the third highest neonatal mortality rate in Indonesia and a maternal mortality rate of 251 deaths per 100,000 live births.
The teams have been trained in solving problems with critical thinking to immediately improve how services are provided, achieve their targets with limited resources and monitor their own progress. The approach adopts a problem-solving methodology for quality improvement, introduced by UNICEF, with financial contributions from the Bill and Melinda Gates Foundation (BMGF), through a partnership with NTB’s Indonesian Public Health Association (IAKMI).
Although both teams were encouraged to start small, the results have been staggering. They have taken on almost a dozen projects over the past three years, focusing mainly on the major causes of maternal and neonatal deaths in the province. These include placenta retention, where placenta remains in the womb after delivery and poses infection and bleeding risks for mothers, and hypothermia and asphyxia, in which babies do not receive enough oxygen.
Among the first projects Desak’s team took on was to make all maternal unit staff fill in patient monitoring reports, allowing them to catch any abnormalities and take prompt actions as early as possible. As a result, the team recorded zero treatment errors in 2021, along with reduced cases of prolonged labour and post-labour heavy bleeding, which can be deadly.
The effort by both teams led to reduced cases of placenta retention to approximately 3 per cent by 2021. Hypothermia cases nosedived from 7.4 per cent in 2019 to 1.2 per cent in 2021, with no related deaths. The fatality rate from asphyxia decreased to approximately 9 per cent by 2021, and the complications and length of stays for newborns in the Neonatal Intensive Care Unit (NICU) were also reduced.
Additionally, the response time for emergency caesarean section surgeries declined from about two hours to 42 minutes in 2021. Meanwhile, response time for referrals from community health centers (puskesmas) also took less than 30 minutes. By the end of 2021, there were no delays in NICU admissions. For mothers and newborns, a split-second difference can be a matter of life and death.
“There is a certain satisfaction when we manage to send home the small babies we have been treating. I still exchange texts with their mothers. A mother once thanked me when we met by chance at a market,” nurse Nur Hayati, the head of the neonatal quality improvement team, recounted proudly.
Pleased with the outcomes, hospital authorities, local health officials and experts who have been supervising the teams are supportive of upscaling the approach to other teams beyond maternal and neonatal units and to other community health facilities and hospitals. UNICEF is working with partners to achieve this.
With little to no cost, the approach can help hospitals cut costs due to shortened inpatient treatment. Quality improvement also becomes absorbed in the work culture among health workers, making it even easier to sustain the programme.
"Self-awareness has grown among the health staff. We can see that trivial things actually have big impacts,"