Changes in obstetric case fatality and early newborn mortality rates in hospitals after the implementation of the Expanding Maternal and Neonatal Survival program in Indonesia: Results from a health information system

Abstract

Objectives Case fatality rates (CFRs) are often used as the key indicator for the measurement of quality of care at hospitals. We examine the trends of obstetric CFRs and very early neonatal mortality rates at hospitals in selected districts of Indonesia after implementation of a facility‐based maternal and neonatal health intervention—the Expanding Maternal and Neonatal Survival (EMAS) program. Methods Random‐effects Poisson regression models were fitted to routine facility data collected from 101 hospitals over approximately 4 years. Predicted incidence rates from the models were used for ascertaining the changes in CFRs and very early neonatal mortality rates during the EMAS intervention period. Results The obstetric CFR from any maternal complications decreased significantly by 50% (adjusted incidence rate ratio [IRR] 0.50; 95% confidence interval [CI] 0.42–0.61) at hospitals after the implementation of the EMAS program. On average, the CFR decreased from 5.4 to 2.6 deaths per 1000 cases of obstetric complications admitted during the program period. The very early neonatal mortality rate (deaths within 24 hours of birth) decreased by 21% (IRR 0.79; 95% CI, 0.65–0.96). Conclusion Our study suggests that overall obstetric case fatality and very early neonatal mortality rates—two indicators for tracking the quality of emergency obstetric care—decreased significantly at hospitals after the implementation of the EMAS intervention program in Indonesia.

Assessing the effect of the Expanding Maternal and Neonatal Survival program on improving stabilization and referral for maternal and newborn complications in Indonesia

“…While it is possible that improvements in stabilization practices seen in this study may have been due to other possible factors outside of EMAS interventions, such as changes in the health insurance scheme JKN, consistency in the effects seen in stabilization practices for both obstetric and newborn complications during all three phases, from over 30 000 cases, provides some confidence that the EMAS program contributed to these positive outcomes. Similar results are reported in a more in‐depth analysis of the monitoring data, which show improvements in obstetric case fatality rates and very early newborn mortality rates at hospitals following the implementation of the EMAS intervention program …”

“…EMAS was implemented in over 400 hospitals and community health centers ( puskesmas ) in 30 districts and cities in six provinces in Indonesia: North Sumatra, Banten, West Java, Central Java, East Java, and South Sulawesi. This program was implemented in three phases—Phase 1: July 2012–March 2016; Phase 2: Jan 2014–Sept 2016; and Phase 3: April 2015–Dec 2016 . A phased approach presented an opportunity to assess progress and identify lessons to improve implementation strategies and approaches as the program expanded into additional districts.…”

“…This program was implemented in three phases-Phase 1: July 2012-March 2016; Phase 2: Jan 2014-Sept 2016; and Phase 3: April 2015-Dec 2016. 32 A phased approach presented an opportunity to assess progress and identify lessons to improve implementation strategies and approaches as the program expanded into additional districts. A new facility-based monitoring system was developed and implemented in 2013 to track key maternal and newborn evidence-based practices and a formal impact evaluation study was conducted in the last 2 years of the program (2015 and 2016) to assess the two main program objectives related to strengthening the referral system and improving quality of care.…”

The effect of Expanding Maternal and Neonatal Survival interventions on improving the coverage of labor monitoring and complication prevention practices in hospitals in Indonesia: A difference‐in‐difference analysis

“…Expanding Maternal and Neonatal Survival approaches targeted improvements in facility self‐monitoring and accountability (clinical governance) as a means to strengthen practices related to the prevention of obstetric and newborn complications. Interventions targeting health facility service strengthening included peer‐to‐peer mentoring in clinical governance, improving routine data collection practices to monitor coverage of high‐impact interventions, use of relevant data to inform decision making, and quarterly assessments of facility readiness against optimal performance standards . EMAS was not designed to strengthen all childbirth practices; the program targeted selected practices to increase the coverage of high‐impact interventions and to prevent complications that contribute significantly to maternal and newborn mortality in Indonesia.…”

Challenges of reducing maternal and neonatal mortality in Indonesia: Ways forward

“…First, the program enhanced a health information system at program hospitals and health centers ( puskesmas) that recorded cause‐specific and total maternal deaths and all newborn deaths. Ahmed et al . utilized the data from the health information system and examined the changes in case fatality rates among women who were admitted with any obstetric complications, and cause‐specific case fatality rates among women who were admitted with postpartum hemorrhage and severe pre‐eclampsia and eclampsia.…”