Midwives and Maternal Midwives and Maternal Mortality:Mortality:

How Effective Has Indonesia’s How Effective Has Indonesia’s Village Midwife Program Been?Village Midwife Program Been?

Shailender Swaminathan (Brown)Shailender Swaminathan (Brown)

Tomoya Matsumoto (GRIPS)Tomoya Matsumoto (GRIPS)

Jeffrey B. Nugent (USC)Jeffrey B. Nugent (USC)

March 2010March 2010

I. MotivationI. Motivation Millennium Development Goal (MDG5) is to Millennium Development Goal (MDG5) is to

reduce the maternal mortality ratio (MMR) by reduce the maternal mortality ratio (MMR) by three quarters between 1990 and 2015. three quarters between 1990 and 2015.

Decline in mortality among adults may be more Decline in mortality among adults may be more important for development than among children important for development than among children

Given budget constraints and difficulty of Given budget constraints and difficulty of reducing MMR, quest for cost-effective reducing MMR, quest for cost-effective measures for doing so is important measures for doing so is important

What program(s) to select?What program(s) to select?

Midwives Programs Commonly Midwives Programs Commonly Identified as Likely CandidateIdentified as Likely Candidate

Historical PrecedentsHistorical Precedents Sweden in Late 19Sweden in Late 19thth Century MMR reduced substantially as Century MMR reduced substantially as

Midwives spread throughout countryMidwives spread throughout country Sri Lanka 1946-60Sri Lanka 1946-60 Malaysia 1960-1985 with 75% reduction in MMRMalaysia 1960-1985 with 75% reduction in MMR Methodological Shortcomings: No controls for other factors Methodological Shortcomings: No controls for other factors

changing concurrently despite the fact that many factors changing concurrently despite the fact that many factors were changing simultaneouslywere changing simultaneously

Consensus Recommendations of International Experts Consensus Recommendations of International Experts and Organizations like WHO and Organizations like WHO The Lancet Maternal Survival Series Steering Group 2006 The Lancet Maternal Survival Series Steering Group 2006

“Maternal Survival 2: Strategies for Reducing Maternal “Maternal Survival 2: Strategies for Reducing Maternal Mortality: Getting on with What Works” Mortality: Getting on with What Works”

Is This priority justifiedIs This priority justified??

Obstacles to Careful Study and Obstacles to Careful Study and Shortcomings in Existing Studies Shortcomings in Existing Studies

Absence of reliable reports on MMRs Absence of reliable reports on MMRs since majority of deliveries are at homesince majority of deliveries are at home

Those programs which have been studied Those programs which have been studied have had inadequate controlshave had inadequate controls

Absence of useful randomized trials Absence of useful randomized trials

Dearth of Randomized Trials on Dearth of Randomized Trials on Determinants of MMRDeterminants of MMR

Those randomized trials that do exist on MMRs Those randomized trials that do exist on MMRs Examine Specific Drugs Effectiveness, other health Examine Specific Drugs Effectiveness, other health

conditions conditions

Most relevant studyMost relevant study: a : a PakistaniPakistani study on the study on the effectiveness of giving short-term effectiveness of giving short-term training to training to traditional midwivestraditional midwives (as opposed to training new (as opposed to training new midwives for a longer period as in the Indonesian midwives for a longer period as in the Indonesian case). case).

Result: by itself at least, this program did not Result: by itself at least, this program did not significantly reduce maternal mortality in significantly reduce maternal mortality in PakistanPakistan (Jokhio et al, 2005). (Jokhio et al, 2005).

II. Indonesia Village Midwife ProgramII. Indonesia Village Midwife Program

Motive: In mid 1980s Indonesia’s MMR Motive: In mid 1980s Indonesia’s MMR >400 per 100,000 live births >400 per 100,000 live births VMP Established in 1989 to train midwivesVMP Established in 1989 to train midwives1 year of training (generally on top of 1 year of training (generally on top of several years of nursing)several years of nursing)Primarily deployed only beginning in 1993 Primarily deployed only beginning in 1993 By 1998 54,000 midwives deployed to By 1998 54,000 midwives deployed to underserved rural villagesunderserved rural villagesMidwives per capita increased more that 10 Midwives per capita increased more that 10 fold, from 0.2 per 1000 to 2.6 per 1000 fold, from 0.2 per 1000 to 2.6 per 1000 between 1990 and 1998.between 1990 and 1998.

Features of Indonesia’s ProgramFeatures of Indonesia’s Program

Known for low cost methods: Burning Known for low cost methods: Burning the Umbilical Cordthe Umbilical Cord

Although Midwives allocated to Although Midwives allocated to underserved areas, Shortcomings underserved areas, Shortcomings

Noted Noted Hatt et al (2007) : Did not reduce urban-Hatt et al (2007) : Did not reduce urban-rural gap in access to emergency care, such rural gap in access to emergency care, such as to Caesarian sections and even widened as to Caesarian sections and even widened itit

Makowiecka et al (2008) VMW services Makowiecka et al (2008) VMW services became less equitable between less remote became less equitable between less remote and more remote areasand more remote areas

Early studies comparing 1989 with 1994 Early studies comparing 1989 with 1994 had shown little MMRate reduction had shown little MMRate reduction

DataDataDemographic and Health Surveys in Demographic and Health Surveys in Indonesia of 1994, 1997 and 2000Indonesia of 1994, 1997 and 2000: Data : Data on Maternal Deaths on Maternal Deaths

MMRate = Maternal deaths at t /100K MMRate = Maternal deaths at t /100K Women aged 15-49Women aged 15-49

Sisterhood Method (WHO 2004) Females Sisterhood Method (WHO 2004) Females asked to identify female siblings born of asked to identify female siblings born of same mother, living or dead. If dead, same mother, living or dead. If dead, asked to identify cause of death, if during asked to identify cause of death, if during pregnancy or within 2 mos. Post-partum. pregnancy or within 2 mos. Post-partum.

This done at national, rural, urban and This done at national, rural, urban and province levelsprovince levels

Explanatory VariablesExplanatory Variables

Fraction of districts with village midwife (VMP)Fraction of districts with village midwife (VMP)

at national, rural, urban, province levels since at national, rural, urban, province levels since 1975 using data from IFLS 1993, 1997, 2000.1975 using data from IFLS 1993, 1997, 2000.

* Other Controls: Age of woman, income, education * Other Controls: Age of woman, income, education of mother, time, alternative service provisionof mother, time, alternative service provision

Regression ModelRegression Model

MMRateMMRater-ur-utt= = αα00+ + αα11time +time +αα22VMP+ VMP+ αα33XXr-ur-u

t t +u+ut t (1)(1)

Midwife Midwife r-ur-utt = = ββ00 + +ββ11time+ time+ ββ22VMP +VMP + β β33 X Xr-ur-u

t t +v+v t t (2)(2)

T = 1975, 1976,………….2000T = 1975, 1976,………….2000

α α 2 2 andand β β22 represent difference in effects of represent difference in effects of

VMP between rural and urban areas where VMP between rural and urban areas where VMP =0 before 1993 (diff in diff)VMP =0 before 1993 (diff in diff)

If other factors constant between pre and post If other factors constant between pre and post program periods, these effects could be program periods, these effects could be causal, causal,

RRRRURAL RR

Results of Table 1Results of Table 1

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

difference in means before and after and difference in means before and after and difference in trends difference in trends

Results of Table 2Results of Table 2

1.1. Almost 11 percentage point Almost 11 percentage point reduction in means of w/o adjusting reduction in means of w/o adjusting for midwife availability (col. 2)for midwife availability (col. 2)

2.2. But after controlling for midwife But after controlling for midwife availability, only a 3% fall (col. 4) availability, only a 3% fall (col. 4)

3.3. Hence over 70% of the fall in rates Hence over 70% of the fall in rates can be explained by VMW can be explained by VMW availabilityavailability

Province level AnalysisProvince level Analysis

Explanatory variables: linear time trend, Explanatory variables: linear time trend, fraction of districts with VMW, province fraction of districts with VMW, province level fixed effectlevel fixed effect

Table 2 shows that VMW availability Table 2 shows that VMW availability explains 6% of intra province changes in explains 6% of intra province changes in MMRate. Use this to predict the MMRates MMRate. Use this to predict the MMRates by province Figure 3by province Figure 3

Compare Figures 3 and 2 Compare Figures 3 and 2

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

RobustnessRobustness

Other access differentials between rural Other access differentials between rural and urban areasand urban areas

Changing the date of startup of the Changing the date of startup of the programprogram

Conclusions Conclusions

Indonesia has made significant progress Indonesia has made significant progress to MDG Goal for 2015to MDG Goal for 2015

But by no means enough to achieve itBut by no means enough to achieve it

Despite small numbers of data points Despite small numbers of data points available , most of the decline achieved available , most of the decline achieved seems to be due to VMPseems to be due to VMP

Possible areas for improvement over timePossible areas for improvement over time

Possible areas for future research Possible areas for future research

Benefits Costs of VMPBenefits Costs of VMP

Much could be done to improve itMuch could be done to improve it

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

Reasons Offered for the Reasons Offered for the Disappointing Results of the VMPDisappointing Results of the VMP

Low quality of trainingLow quality of training Lack of financing and access to hospitals when neededLack of financing and access to hospitals when needed Lack of sustainability: urban born women not happy Lack of sustainability: urban born women not happy

about having to live in villages w/o many amenitiesabout having to live in villages w/o many amenities Insufficient incentives for high quality service deliveryInsufficient incentives for high quality service delivery Shortages of materials and equipment at local levelShortages of materials and equipment at local level Numerous transport and communications problems Numerous transport and communications problems

locallylocally

Conclusion: Despite its promise, Not obvious that the Conclusion: Despite its promise, Not obvious that the program has had significant effects on MMRprogram has had significant effects on MMR

Other Changes Affecting ResultsOther Changes Affecting Results

1999 Decentralization Program Failures: local 1999 Decentralization Program Failures: local governments revenue constrained, hence often governments revenue constrained, hence often cannot pay the midwives and buy the suppliescannot pay the midwives and buy the supplies

1997-8 financial crisis: loss of income, inflation, 1997-8 financial crisis: loss of income, inflation, supply shortages weakening provisions at local supply shortages weakening provisions at local levellevel

Gradual increase in malaria which would Gradual increase in malaria which would weaken pregnant women and make them more weaken pregnant women and make them more vulnerable to infection, death during pregnancy vulnerable to infection, death during pregnancy and childbirthand childbirth

Shortcomings and ExtensionsShortcomings and Extensions

MMR data not reliable: Could use other indicators MMR data not reliable: Could use other indicators excessive bleeding at birth, prompt referral of excessive bleeding at birth, prompt referral of complicated cases.complicated cases.

Use of still other sources of midwife availability. How Use of still other sources of midwife availability. How sensitive would results be to such alternatives. sensitive would results be to such alternatives.

Experience as of 2000 quite short, future rounds of Experience as of 2000 quite short, future rounds of IFLS should provide more reliable estimates IFLS should provide more reliable estimates

How much substitution among providers has there How much substitution among providers has there been? been?

Has the quality of care by other providers been Has the quality of care by other providers been affected by presence of VMW? affected by presence of VMW?