ected. Results of the intervention, which consisted of trainina TBAs. midwives. and health center &tors. were p&tive inasmuch (ISthere was on increase in referrals of breech presentation. prohmged lobor and intraportumfever in the intervention oreo. Pregnant women in general were &o more often referred in the intervention area as compared to the control area. The same outcome was seen in referrals of t~eonates weighing under 2000 or more than 4000 g. At the district hospital level. o great number ofprocedures were left to generalpractitioners with quite s&factory results. Conclusionr drawn from our experience are that: (I) obstetric core must of necessity be delegated to TBAs, midwives, andgeneralpractitioners; (2) TBAs can be taught to recognize danger signs; (3) general practitioners ore able to do such procedures as curettage. v*or forceps deliveries. and monual removal of placenta. Keywordo: Maternity care; Traditional attendant; Obstetric procedures.
birth
It would be very difiicult if not virtually impossible for a developing country like ladonesia to provide optimal obstetric care for all its people. Resides lacking the necessary resources, distances between the numerous islands create huge problems. So it is no wonder that 70%~SOYYof deliveries are still attended by traditional birth attendants (TBAs). Not only are their fees modest, but
they are also willing to cook and take care of household chores while their patients are resting. TBAs are generally considered almost part of the family. The Indonesian Health Department initiated a TBA training program several years ago, but a 1987 survey cooducted by the Research Unit of the Padjadjaran University Medical Faculty found that their skills and knowledge were very poor. This could be ascribed to the fact that most TBAs were illiterate and the training program too dificult for them. In designing that course, too little attention had been paid to the special materials needed for a group with such limitations. Based on the Research Unit’s findings, a retraining program was begun to enable TBAs to recognize high risk cases [l-3]. Simplitied pictorial cards were designed to instruct these women and scales were also devised with distinctive coloring to indicate different birthweights. A knowledge, attitude and practice (KAP) study of the health center personnel (1 doctor plus 7 or 8 paramedics, including a midwife) revealed that much was also lacking at this level. Although health center physicians were provided with guidelines on care for medium risk patients and diagnosis of high risk cases for referral to the district hospital. the midwife and doctors lacked the skills and confidence to carry out the necessary procedures. A KAP study of the district hospital staff also showed that obstetric care at this level also did not reet expectations; quite often diflicult procedures and complicated deliveries were left to general practitioners whenever the obstetrician was unavailabie. To more accur-
ately evaluate the role of the TBAs, midwives, and general practitioners in obstetric care, a Z-year study was started in 1988, covering their practice at all levels. Methodology Health center midwives were first instructed and they later taught the TBAs with the help of other personnel, under the supervision of one of the Research Unit physicians. The TBA cuniculum. of 1 month’s duration. consisted of discu&ons lectures, demo&ations, field trips, and dmulations. Monitoring was done by interviewers to follow up the TBAs’ performance. Two physicians were soeciallv trained in the tecbnioue of verbal autopsj. Special interviews werk designed to evaluate the KAP of health center staff. All neonatal and maternal cases referred to a health center or district hospital were followed up. In the case of deaths at the health center or district hospital, the records were reviewed and treatment at the various levels evaluated by a senior obstetrician. A control area was selected where TBAs were not trained. Results and dlseuasiw To evaluate TBA performances after the special training two sources were used, one from interviews of pregnant women and the other from referral reports at the health center. In general, the training program had some impact on the quality of obstetric care in the intervention area as evidenced by the greater number of referrals from TBAs in the interested area as compared to the control area. However, it was also seen that too few abnormal cases were referred for lack of recognition. Low weight babies were also not very often referred as they were not considered to be at risk. An analysis of 20 maternal deaths also revealed that the quality of care was still unacceptable. Two women died from eclampsia, difficult for TBAs to diagnose. Postpartum bleeding due to atonia uteri
and retention of the olacenta were often referred too late. The he&h center’s performance also left much to be desired. Whenever emergency cases were referred. valuable time was I&t in locating the doctor or a paramedic. The midwives were reluctant to do a manual removal of the placenta as were the health care doctors. Forceps or vacuum extractions were rarely performed. Other simple procedures such as evacuation of an incomplete abortion were not carried out there. The unfavorable effect on the TBAs is medictable. That the TBAs did not refer as miny cases as would be desirable is explained by the fact that some of them lacked confidence in the health center staff and advised their patients to go directly to the district hospital, where they were more likely to receive appropriate care. When questioned, the health center doctors confessed to uncertaintv about their own skills and knowledge. F&m a study of referral cases to the district hospital and the Central Provincial Hospital it can be seen that health center doctors did not adhere to guidelines provided for management of premature rup ture of membranes or prolonged labor (especially the second stage), and for stabilizadon of shocked patients or handling of other emergencies. However, with proper instruction, these physicians should be able to do many procedures safely as has been demonstrated by their colleagues in the district hospitals. At the district hospital level certain inadequacies were noted; prominent among them are delays in initiating treatment of em&gency cases. The resident doctor on duty mav be overworked and cannot promptly- care for referred cases. Delay was also caused because no preparations were made beforehand, so essential measures such as blood transfusion are not possible quickly. Preparing an operating room is a time-consuming effort in itself, and when the surgical staff also has to be located, the problem is compounded. When the obstetrician is not available, a general practitioner specially trained ai tixe district
hospital should be able to do a czsarean section. As matters stand right now, in the absence of the obstetrician, -&ent:; requiring an operation for ruptured ectopic pregnancy, ruptured uterus or who need to be delivered by cesarean section are sent to the chief provincial referral hospital, a trip of some 2-3 h. During the year df the study, the following number of interventions were wrformed: 108 cesarean sections, 51 I cwetta& 70 vacuum extractions~ and 12 forceps extractions. Obviously this would be too much for one obstetrician to handle. Most of the vacuum and forceps extractions as well as the curettaws were done bv menera practitioners. tius, it should be reiat~ely easi to teach the general practitioners to also do more advanced obstetric and gynecologic surgery than at present, foremost, of course. cesarean section.
Delegation of obstetric care remains necessary in Indonesia. Trained TBAs still lack certain skills and knowledge in recognizing risk factors but they can be taught how to do so. General practitioners who have received ap-
propriate instruction obstetric p:ncedures tion. forceps delivery, removal of placenta for close monitoring
are able to perform such as vacuum extraccurettage,
and manual
and can be responsible of prolonged labor.
birth
It would be very difiicult if not virtually impossible for a developing country like ladonesia to provide optimal obstetric care for all its people. Resides lacking the necessary resources, distances between the numerous islands create huge problems. So it is no wonder that 70%~SOYYof deliveries are still attended by traditional birth attendants (TBAs). Not only are their fees modest, but
they are also willing to cook and take care of household chores while their patients are resting. TBAs are generally considered almost part of the family. The Indonesian Health Department initiated a TBA training program several years ago, but a 1987 survey cooducted by the Research Unit of the Padjadjaran University Medical Faculty found that their skills and knowledge were very poor. This could be ascribed to the fact that most TBAs were illiterate and the training program too dificult for them. In designing that course, too little attention had been paid to the special materials needed for a group with such limitations. Based on the Research Unit’s findings, a retraining program was begun to enable TBAs to recognize high risk cases [l-3]. Simplitied pictorial cards were designed to instruct these women and scales were also devised with distinctive coloring to indicate different birthweights. A knowledge, attitude and practice (KAP) study of the health center personnel (1 doctor plus 7 or 8 paramedics, including a midwife) revealed that much was also lacking at this level. Although health center physicians were provided with guidelines on care for medium risk patients and diagnosis of high risk cases for referral to the district hospital. the midwife and doctors lacked the skills and confidence to carry out the necessary procedures. A KAP study of the district hospital staff also showed that obstetric care at this level also did not reet expectations; quite often diflicult procedures and complicated deliveries were left to general practitioners whenever the obstetrician was unavailabie. To more accur-
ately evaluate the role of the TBAs, midwives, and general practitioners in obstetric care, a Z-year study was started in 1988, covering their practice at all levels. Methodology Health center midwives were first instructed and they later taught the TBAs with the help of other personnel, under the supervision of one of the Research Unit physicians. The TBA cuniculum. of 1 month’s duration. consisted of discu&ons lectures, demo&ations, field trips, and dmulations. Monitoring was done by interviewers to follow up the TBAs’ performance. Two physicians were soeciallv trained in the tecbnioue of verbal autopsj. Special interviews werk designed to evaluate the KAP of health center staff. All neonatal and maternal cases referred to a health center or district hospital were followed up. In the case of deaths at the health center or district hospital, the records were reviewed and treatment at the various levels evaluated by a senior obstetrician. A control area was selected where TBAs were not trained. Results and dlseuasiw To evaluate TBA performances after the special training two sources were used, one from interviews of pregnant women and the other from referral reports at the health center. In general, the training program had some impact on the quality of obstetric care in the intervention area as evidenced by the greater number of referrals from TBAs in the interested area as compared to the control area. However, it was also seen that too few abnormal cases were referred for lack of recognition. Low weight babies were also not very often referred as they were not considered to be at risk. An analysis of 20 maternal deaths also revealed that the quality of care was still unacceptable. Two women died from eclampsia, difficult for TBAs to diagnose. Postpartum bleeding due to atonia uteri
and retention of the olacenta were often referred too late. The he&h center’s performance also left much to be desired. Whenever emergency cases were referred. valuable time was I&t in locating the doctor or a paramedic. The midwives were reluctant to do a manual removal of the placenta as were the health care doctors. Forceps or vacuum extractions were rarely performed. Other simple procedures such as evacuation of an incomplete abortion were not carried out there. The unfavorable effect on the TBAs is medictable. That the TBAs did not refer as miny cases as would be desirable is explained by the fact that some of them lacked confidence in the health center staff and advised their patients to go directly to the district hospital, where they were more likely to receive appropriate care. When questioned, the health center doctors confessed to uncertaintv about their own skills and knowledge. F&m a study of referral cases to the district hospital and the Central Provincial Hospital it can be seen that health center doctors did not adhere to guidelines provided for management of premature rup ture of membranes or prolonged labor (especially the second stage), and for stabilizadon of shocked patients or handling of other emergencies. However, with proper instruction, these physicians should be able to do many procedures safely as has been demonstrated by their colleagues in the district hospitals. At the district hospital level certain inadequacies were noted; prominent among them are delays in initiating treatment of em&gency cases. The resident doctor on duty mav be overworked and cannot promptly- care for referred cases. Delay was also caused because no preparations were made beforehand, so essential measures such as blood transfusion are not possible quickly. Preparing an operating room is a time-consuming effort in itself, and when the surgical staff also has to be located, the problem is compounded. When the obstetrician is not available, a general practitioner specially trained ai tixe district
hospital should be able to do a czsarean section. As matters stand right now, in the absence of the obstetrician, -&ent:; requiring an operation for ruptured ectopic pregnancy, ruptured uterus or who need to be delivered by cesarean section are sent to the chief provincial referral hospital, a trip of some 2-3 h. During the year df the study, the following number of interventions were wrformed: 108 cesarean sections, 51 I cwetta& 70 vacuum extractions~ and 12 forceps extractions. Obviously this would be too much for one obstetrician to handle. Most of the vacuum and forceps extractions as well as the curettaws were done bv menera practitioners. tius, it should be reiat~ely easi to teach the general practitioners to also do more advanced obstetric and gynecologic surgery than at present, foremost, of course. cesarean section.
Delegation of obstetric care remains necessary in Indonesia. Trained TBAs still lack certain skills and knowledge in recognizing risk factors but they can be taught how to do so. General practitioners who have received ap-
propriate instruction obstetric p:ncedures tion. forceps delivery, removal of placenta for close monitoring
are able to perform such as vacuum extraccurettage,
and manual
and can be responsible of prolonged labor.
