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

Abstract

Objective To assess whether the Expanding Maternal and Neonatal Survival (EMAS) program was associated with improved care provided during hospital‐based childbirth. Methods A quasi‐experimental study with two rounds of data collection examined whether EMAS interventions improved facility‐based labor and childbirth care. Direct clinical observations were conducted for 1208 deliveries across 13 hospitals in 12 districts. Primary outcome measures included implementation of standard practices to reduce the risk of complications during labor and childbirth for both women and newborns. Results Adjusted difference‐in‐difference analysis compared the mean difference in quality scores between EMAS intervention hospitals and comparison sites and consistently found significantly better performance in EMAS sites: 14 points higher for labor monitoring (β‐coefficient 14.1; 95% confidence interval [CI], 7.1–21.0); 38 points higher for newborn resuscitation readiness (β‐coefficient 38.1; 95% CI, 31.1–45.2); and 33 points higher for infection prevention practices (β‐coefficient 32.6; 95% CI, 28.5–36.8). Conclusion EMAS approaches emphasizing facility readiness and adherence to performance standards significantly improved labor monitoring and complication prevention practices during childbirth.

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

“…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 …”

“…Data were collected at two time periods (2015 and 2016) from a total of 13 hospitals and 24 puskesmas , and included 2100 clinical observations of obstetric and newborn patients. The study sites, selection, and data collection processes are described in detail in companion articles …”

“…The United States Agency for International Development (USAID) funded the Expanding Maternal and Neonatal Survival (EMAS) program (September 2011 to March 2017) to support the government of Indonesia in reducing maternal and newborn mortality by strengthening the quality of care provided in puskesmas and hospitals and in strengthening district‐level referral pathways. The EMAS program is fully described in the overview paper published in this Supplement …”

“…Beneficiaries of JKN are entitled to comprehensive maternity benefits, including institutional childbirth coverage for normal births at the puskesmas level, however, pregnant women are not allowed to directly seek treatment at a hospital or specialist clinic, except in an emergency situation or with a referral letter. 22,26 The United States Agency for International Development (USAID) funded the Expanding Maternal and Neonatal Survival (EMAS) program (September 2011 to March 2017) to support the government of Indonesia in reducing maternal and newborn mortality by strengthening the quality of care 30 provided in puskesmas and hospitals and in strengthening district-level referral pathways. The EMAS program is fully described in the overview paper published in this Supplement.…”

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

“…Two rounds of surveys were carried out at selected hospitals in EMAS districts, as the intervention arm, and at sampled non‐EMAS facilities, as the control arm. Tholandi et al . used the data from the quasi‐experimental study to examine the changes in quality of care and to compare the differences in the quality of care improvement between the EMAS and non‐EMAS facilities using the difference‐in‐difference analytical method.…”