Indonesia’s maternal mortality rate is one of the highest in south-east Asia. One East Java district has introduced a novel scheme to reduce those deaths.
The instruments used are not sterile and can lead to infection. The traditional healer, or dukun in Indonesian language or Bahasa, may not be able to deal with complications during labour, and by the time the mother gets to a local clinic it may be too late.
A dukun in Ngawi, East Java escorts a pregnant woman to a midwife
As a result, maternal mortality in Indonesia is high compared to most south-east Asian countries. In 2005, there were an estimated 262 maternal deaths per 100 000 live births, compared with 39 per 100 000 in Malaysia and 6 per 100 000 in Singapore. Figures for Papua province from 2003 show even higher death rates: 396 per 100 000 live births.
The chief cause of maternal death in Indonesia is bleeding, followed by eclampsia, infection, and the complications of abortion and prolonged labour. Most of these deaths occur with births handled by traditional birth attendants rather than by medically trained health-care professionals.
Many families prefer to use a dukun because of traditional beliefs and because it is a cheaper option than using a trained midwife or going to hospital. In addition, these traditional birth attendants do household chores while mothers recover.
A scheme in Ngawi district in East Java has been initiated to try to ensure that a midwife or other trained birth attendant assists deliveries. Since 2006, dukun are given incentives of up to IDR 100 000 (US$ 12) for referring pregnant women to skilled birth attendants or community-based midwives. Funding comes from the local government budget.
Mbah Dinah, 60, a traditional healer in Ngawi, said, “We escort the pregnant woman to the community health centre during daylight. At night, we escort them to the midwife’s house.”
Additionally, the dukun receive a small sum of money when they assist a midwife. They are responsible for taking care of the cord and for bathing the newborn – supervised by the midwife – during the first week. The patient makes the payment; the amount depends on the length and type of services provided.
This way, dukun do not feel threatened by the arrival of a skilled birth attendant or community-based midwife in their area, but are happy to cooperate.
Sumarih, 24, is from the village of Majaseem and was nine months pregnant. She said she preferred to be examined and give birth aided by a midwife because she feels it is safer: “Devices that are used are sterile and midwives know how to handle any complications fast.” She was examined monthly in early pregnancy, and every week in the ninth month.
Traditional healers in Ngawi, East Java.
The scheme is proving successful. In 1984, a total of 86% of deliveries in Ngawi were aided by dukun, compared with fewer than 1% of deliveries today. Maternal deaths also have decreased: while 15 mothers died during delivery in 2002, this number dropped to 9 in 2006.
Awareness of the risks of delaying transfer of pregnant women to health centres also has grown as a result of the Program Gerakan Sayang Ibu (To Love Mother Programme in Bahasa). This information programme prompted many villages to provide transportation to transfer pregnant women either to community health centres or midwife delivery huts.
These initiatives are part of WHO’s Making Pregnancy Safer strategy, which was launched in 1999 with support from the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF) and the World Bank. Making Pregnancy Safer in Indonesia has three key principles: every delivery should be attended by a skilled birth attendant, every complication should be referred and managed appropriately, and all reproductive-age females should have access to contraceptives and post-abortion care. The Indonesian government has set a target to lower the maternal mortality rate to 125 per 100 000 live births by 2010.
The ministry of health initiated a midwifery education programme from 1989 to 1996 that trained more than 54 000 community-based midwives. Due to this programme, the proportion of deliveries assisted by a skilled attendant throughout Indonesia has risen from 25% in the early 1990s to 76% in 2006.
“We know what interventions are necessary in order to save pregnant women and newborns’ lives,” said Dr Monir Islam, Director of the Making Pregnancy Safer department at WHO. “The technical battle we have won; now the time has come to win the political battle for policy changes and increased investment.” ■
Cininta Analen, Ugaikagopa
Heather Kovich, M.D. N Engl J Med 2017; 376:1307-1309April 6, 2017DOI: 10.1056/NEJMp1613899
“Have I told you that I’m converting my garage into a workout room?” my friend asks. We are roaming the compound, our eyes fixed on the enormous, changing sky, oblivious to the tumbleweeds and empty plastic bottles skittering across our path.
“I’m hiring one of the maintenance guys to put down laminate floors. They’re even installing a window.”
The sun, down behind the Carrizo Mountains, streaks the sky in a saffron finale. Our dogs chase a curious prairie dog back into its den.
My mind turns over the implications of my friend’s home-renovation project, and I am filled with happy relief. We circle the hospital and return to our street. I can’t voice my feeling — she’d be disappointed that I’d doubted her commitment. Instead, I say, “That’s a lot of money to put into the hospital’s house, but it sounds awesome. I can’t wait to see it.”
This tension defines our lives as rural primary care physicians. Our patients put it the most bluntly: “And how long will you be staying, doctor?”
Over the past decade, efforts to increase access to health care in the United States have focused on insurance coverage. Meanwhile, a shortage of physicians is still the limiting factor in rural communities. Twenty percent of the U.S. population is rural, but only 11% of physicians practice in rural settings,1 even though residents of rural areas are older and have worse health indicators than their urban counterparts.2 Programs like the National Health Service Corps and state loan-repayment arrangements lure physicians to rural settings, but these physicians churn like lottery balls in a drum.3 The winning combination is a good doc who stays.
My patients asked me The Question at every visit for several years, and it irritated me every time. I would paste on a smile and answer with some version of “I’m not sure,” dodging the follow-up inquiries about what my husband does and whether he likes the area. Their questions implied what the Dartmouth Atlas made explicit: physician supply is driven by where physicians want to live,4 not by the health needs of the community. If we like it, maybe we’ll stay.
Before moving to rural New Mexico, I had been itinerant. Medical school on the East Coast. Residency on the West Coast. Locums abroad. So I expected to stay for 2 or 3 years — a tenure that seemed respectable to me. It was not the answer my patients wanted. I rationalized my defensiveness. Why did turnover matter if the care was good? My colleagues in big cities changed jobs after a few years, too.
As I started my practice, the patients seemed complicated: diabetes, rheumatoid arthritis, cirrhosis, often all three. I was grateful they’d had a series of very good doctors. Their problems had been worked up, and the plans were clear. They’d had their cancer screenings. When it was indicated, they were on aspirin and statins. Hardly any were on long-term opiates.
In my first month I diagnosed a patient with hyperthyroidism. “Where’s the nearest endocrinologist?” I asked a veteran internist.
She was puzzled. “Why would you refer? Can’t you order the ablation?”
I learned to adjust my care to the geography. Some of my patients live hours from our hospital, on dirt roads become impassable in thunderstorms or snow. The nearest tertiary care hospital is another 3 hours away. We don’t refer often. If my patients do need a specialist, they go for a visit or two — I can always e-mail the rheumatologist or cardiologist if I have a question about adjusting their treatment.
I appreciate the continuity. I see my patients in our hospital and back again in clinic. I don’t need to request stacks of records from when they were septic, with diabetic ketoacidosis. I was in the ICU with them, ordering their antibiotics and insulin drip, explaining their condition to family members who are also my patients.
Caring for entire families helps me understand my community. I know that a patient is stressed because her son struggles with alcoholism: I’ve admitted him several times with pancreatitis. I know another patient can’t focus on her diabetes because she is still grieving her mother’s death: for years she wheeled her mother into my clinic for monthly appointments. When a teenager returns from a first year at college and asks for birth control, I remember her mother crying in my office months earlier, overwhelmed with pride and worry at having her first baby move so far away.
The patients weary of explaining all this — their tragedies, triumphs, and transformations — to a new face every few years, no matter how bright or kind that new face is. Seven years in, I understand why my patients would be disappointed if I left. As their doctor, I would be, too.
I’ve seen plenty of doctors cycle through. Smart, sincere, and hardworking, they came for a year or two or four — to pay back loans, to gain experience before fellowship, to have an adventure before settling down. Their service is no small thing: we depend on them. When I see Dr. C.’s copperplate handwriting in patient charts, I remember her warmth and meticulousness. When I use the clinic ultrasound, I see the reams of forms Dr. W. used to justify its purchase. I wistfully think of Drs. B. and D., a married couple of fun, razor-sharp clinicians who taught me a lot about medicine and parenting over 2 years. And I have a small, dusty bottle of sweet-tea–flavored vodka on my shelf from Dr. H. He left 6 years ago and gave it to someone else, who left and passed it along to me. Although the vodka is not to my taste, I like the reminder of Dr. H. He still recruits for us, sending us residents from his academic post.
Like my patients, I weary of explaining my history to new colleagues year after year. Also like my patients, I am immensely grateful for the physicians who have been here longer than I. We doctors are a close group. We rent housing from the hospital on its adjacent compound. We gather for potlucks and barbecues. Our children play together. I have knocked on a neighbor’s door at 10 p.m. to borrow a cup of sugar.
So, like my patients, I tire of saying goodbye. When doctors leave a remote practice, they go far away. Getting together with them involves airlines, time zones, and unsettled feelings. There is guilt for the person who left, insecurity for the one left behind. I feel it acutely: Are they really happier somewhere else? Should I leave too? It sounds nice to live in a neighborhood with Trader Joe’s, high-speed Internet, and baby-sitting grandparents.
Now, before I make friends, I gauge how long someone will stay. I learned this move from my patients, though I’m not yet as blunt. I remember how much “How long will be you staying?” irritated me. Instead, I observe: Do they plant a garden, spruce up the hospital’s house, adopt a stray dog? I hesitate to pull up a chair unless they’re going to lay down some laminate floors and stay awhile.
Patients still ask me The Question at least twice a day. “You’re not leaving soon, are you?” My smile comes naturally. I feel valued. I tell them honestly, I have no plan. I don’t tell them that I’m undecided about buying a new dining-room table. Mine is falling apart, but I’m torn between buying a nice one that fits this space and getting a cheap one. If I move, I might want something different in a new house.
I talk it over with my friend as we walk our dogs in the evening. Her eyes widen slightly, but she hesitates only for a second. “Buy a nice one for this space,” she says.
Disclosure forms provided by the author are available at NEJM.org.
From the Northern Navajo Medical Center, Shiprock, NM.
1 Rosenblatt RA, Chen FM, Lishner DM, Doescher MP. The future of family medicine and implications for rural primary care physician supply. Seattle: WWAMI Rural Health Center, August 2010 (https://depts.washington.edu/uwrhrc/uploads/RHRC_FR125_Rosenblatt.pdf).
2 Institute of Medicine. Quality through collaboration: the future of rural health. Washington, DC: National Academies Press, 2005 (http://www.nap.edu/catalog/11140.html).
4 Goodman DC. Linking workforce policy to health care reform. Invited testimony to the United States Senate Committee on Finance, March 12, 2009 (http://www.dartmouthatlas.org/downloads/press/Goodman_Sen_Fin_2009.pdf).
Margot Hartmann, M.D., Ph.D., and Jason Graziadei, B.A. N Engl J Med 2017; 376:1306-1307April 6, 2017DOI: 10.1056/NEJMp1701449 Share:Article References Metrics
Small community hospitals throughout the United States are facing threats including low volume, declining reimbursements, and staffing challenges.1,2 Nantucket Cottage Hospital, a 19-bed facility and one of the smallest hospitals in Massachusetts, must also navigate the complexity of operating on an island 30 miles offshore, where the year-round population of 15,000 swells to more than 60,000 during the summer months.
There is no off-the-shelf staffing model that works in the clinical environment of our emergency department (ED). The ED provides care to more than 10,000 patients every year, but the majority of them present between Memorial Day and Columbus Day. Our ED team sees everything you would expect at a community hospital, plus more than our share of tickborne illnesses (ranging from routine to catastrophic), whose incidence is far higher on Nantucket than in many other places in Massachusetts.3
The evolution of emergency services on the island has been dictated by the potential risk of high-acuity, low-frequency events for a small hospital with limited human resources. For us, a mass casualty incident is a van rollover with 16 elderly victims or a carbon monoxide leak in an overcrowded basement apartment. Nantucket’s location means that medical transfers to a tertiary care hospital on the mainland aren’t always possible. Inclement weather or fog can prevent Boston MedFlight from making it to the island, and in the post-9/11 world, the Coast Guard isn’t always available. The tricky equation of appropriate and efficient ED staffing4 is made more complex by Nantucket’s geography and seasonality. So despite our low clinical volume, we need emergency physicians with high skill levels.
For “the season” on Nantucket, when our population explodes and the demands on our ED surge, our answer for many years was to put together a varied team of board-certified physicians that tended to come back year after year with their families, but with no guarantee on either side. We were hiring 30 to 32 people from Memorial Day to Columbus Day in 2-week shifts in order to have 24/7 coverage. Though we were certainly fortunate that a stint on Nantucket was attractive to some physicians and their families, we had to house them, find ways to accommodate them with their dogs and their grandmothers, and organize everything for their stay, in addition to coordinating travel on the ferries to and from the island. A big part of the challenge was juggling these teams amid the island’s ongoing housing crunch.
We also had to manage physicians’ expectations of work versus vacation — discouraging the perception that the assignment would entail sitting on the beach with a pager. Whereas urban and suburban institutions may have teams from cardiology, pulmonology, psychiatry, and other specialties on call to support the ED, our rotating ED team and the few year-round island doctors were our total resources. Some people saw that limitation as a wonderful opportunity to exercise their problem-solving skills in a low-resource environment, but not everyone found it so thrilling.
So we ended up with a mix of summer providers that we had to reinvent every year, always under pressure to get it right. Before each summer, we would launch a process involving recruiting, licensing and credentialing, and managing various logistic challenges. It was not a way to create a cohesive team; some visiting physicians didn’t have a real stake in this place after they left.
In recruiting this team, it was difficult to convey the types of judgment calls that needed to be made in a place like Nantucket to physicians who would be here for a very short time but were being entrusted to provide care during our highest-volume period. It was anxiety-provoking to recognize that we might not have the best match between resources and patient needs or that a visiting doctor might be on service with a visiting nurse, neither of whom was schooled in our particular practice environment. These visiting providers had to constantly keep track of factors that might be unfamiliar to them: What staff members are on island and on call? Is orthopedics here? What’s the current volume? Will the weather prevent MedFlight from getting here?
Assembling the summer ED team became increasingly difficult. The usual cadre was aging, and some clinicians chose not to return. Seeing that the model that had evolved wasn’t serving us and couldn’t be sustained, we began to think about an alternative. Our chief medical officer identified an emergency staffing group — MEP Health, now called U.S. Acute Care Solutions — that, far from being daunted by a new problem, was intrigued by Nantucket and its unusual circumstances. Aiming to balance delivery of high-quality medicine — an ever-evolving goal — with continuity provided by a core team that understands the puzzle we face, we negotiated a trial agreement. MEP Health became the employer of the existing year-round providers, including physicians and physician assistants, as well as some longtime summer team members, and supplemented them with rotating clinicians from its higher-volume hospitals. It took on responsibility for scheduling, peer review, and quality metrics, while building awareness of Nantucket-specific aspects of clinical judgment, so that we no longer have to constantly reorient personnel. This model forces a careful comparison between the cost of subcontracting ED staffing and the cost of directly hiring six or more ED physician and PAs, even if we could recruit them to the island and figure out how to enable them to buy into the housing market. Most of all, it takes advantage of the continuity and stability of our year-round ED base, while allowing us to stay current as medicine evolves.
Now we don’t have to worry about filling our schedule for next summer or about depending on a locum agency for physicians whose quality we have no way of judging in advance. Instead, we can focus on becoming fluent in the type of medicine that best serves our island.
Disclosure forms provided by the authors are available at NEJM.org.
From Nantucket Cottage Hospital, Nantucket, MA.
Susan Mann, M.D., Kimberlee McKay, M.D., and Haywood Brown, M.D.
N Engl J Med 2017; 376:1304-1305April 6, 2017DOI: 10.1056/NEJMp1700485
In a rural Minnesota town with fewer than 5000 residents, an 18-year-old woman with a term pregnancy goes into labor in a hospital that performs about 75 deliveries per year. Her pregnancy has been uncomplicated, but chorioamnionitis develops during labor and she undergoes a primary cesarean delivery for arrest of descent during the second stage of labor. Her low-risk pregnancy has become high risk — a common story for intrapartum obstetrical care in any hospital, but one that can have deadly consequences in a hospital with fewer resources, including a small staff and limited blood-bank capacity. The woman has a severe postpartum hemorrhage and loses more than 2 liters of blood. She is given the usual uterotonic medications and surgical intervention with B-Lynch suture placement, but they prove ineffective.
The lone obstetrician in the hospital is about to perform a hysterectomy when she recalls a conversation she had 2 weeks earlier with the obstetrical medical director of her hospital system about a program for team training and simulation for obstetrical emergencies that was being offered at her hospital. The director encouraged the obstetrician to reach out regarding safety concerns and left a card with her cell-phone number. Running low on options, the obstetrician contacts the director, who recommends giving the patient a transfusion from the hospital’s very limited blood supply. The director then facilitates consultation with Avera eCARE, a telehealth service that provides real-time specialty expertise to lower-resource care settings.
The teams at Avera arrange transport by helicopter to a tertiary care hospital in Sioux Falls, South Dakota, a 20-minute flight. The patient arrives 2 hours after the initial call was placed, and the telehealth specialists support both the transporting-hospital care team in stabilizing the patient for transport and the receiving care teams in intensive care and interventional radiology. The patient, who was about to have a life-altering and possibly life-threatening hysterectomy, instead undergoes a uterine artery embolization and further stabilization in the intensive care unit (ICU) and is discharged 3 days later.
More than 60% of U.S. hospitals that provide obstetrical care perform fewer than 1000 deliveries per year, or fewer than 3 a day. A review of obstetrical outcomes in 600 rural U.S. hospitals and low-volume, nonteaching hospitals — lower-resource hospitals — revealed that they had higher maternal morbidity than teaching hospitals. The possible issues identified in the lower-resource settings included maintenance of competencies and recruitment of staff.1
In the United States from 1998 to 2008, delivery and postpartum hospitalizations that resulted in maternal mortality and severe maternal morbidity increased by 66% and 75%, respectively.2 The Centers for Disease Control and Prevention and state departments of health have recognized the difficulty of obtaining accurate data pertaining to severe maternal complications and pregnancy-related deaths owing to varied definitions and reporting requirements. Even less information is available regarding the setting in which these cases occurred — urban versus rural and academic centers versus community hospitals. Rural health care centers have been essential for patients, but many of these smaller hospitals have shut down their maternity services.3 For a patient in a rural setting, frequent severe weather and long distances may impede access to a larger hospital. Is it reasonable for these women to drive for hours to get to a larger medical center, or can we do more to support obstetrical practitioners in remote settings?
We believe that Avera’s approach can provide a model for other parts of the country, where a Maternal Health Compact could be created linking lower-resource hospitals with tertiary care hospitals, with the goal of transporting patients to the appropriate facility when possible and making care as safe as possible locally when transport is not an option. Telehealth services in obstetrics can help to bridge the gap in three ways: facilitating transport of patients, supporting care provided remotely, and assisting in local quality-improvement activities.
Under a Maternal Health Compact, a tertiary care hospital provides services to its referring lower-resource hospitals for high-risk patients. Smaller hospitals also benefit from increased collaborations in which, for instance, the tertiary care hospital runs simulations of obstetrical emergencies and assists with quality-improvement activities such as implementation of hemorrhage-treatment algorithms. Such collaborative work can be done in person or through telemedicine connections.
National efforts at improving obstetrical care have stopped short of addressing rare emergencies that can occur in a lower-resource hospital. In 2015, for example, the American Congress of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine released the Obstetric Care Consensus on Levels of Maternal Care, which delineates criteria for identifying women at considerable health risk (such as those with placenta previa, placenta accreta, or preeclampsia with severe features) who should be cared for at a hospital with appropriate staffing and resources to avert obstetrical complications and related deaths.4 Unfortunately, the consensus statement does not address the situation of an 18-year-old with an unexpected severe hemorrhage. Yet with better preparation and planning through a Maternal Health Compact, hospitals could be ready for these crises.
Telehealth is already used in many disciplines in which there is a mismatch between patient needs and specialty expertise, such as dermatology, geriatrics, and mental health, but to our knowledge, there has been no telehealth model for obstetrical care for an acutely high-risk pregnant woman in a lower-resource hospital. In the case of the Minnesota patient, a coordinated telehealth team intervened quickly and effectively; they worked with the rural hospital to stabilize the patient, arranged transport, and prepared the tertiary care hospital.
Through a Maternal Health Compact, physicians and nurses made available to lower-resource hospitals through a video link can help manage on-site obstetrical emergencies. Physicians make recommendations regarding care, while nurses support the nurse in the field by documenting the patient’s course and care in the medical record and facilitating communication with the local pharmacy to obtain necessary medications. The telehealth program developed at Avera, for example, houses under one roof a variety of medical departments — ICU, pharmacy, emergency, and others — to provide continual specialty care to partner care facilities. This kind of coordination is invaluable to patients.
The development and implementation of national standards supports the consistency of obstetrical care. The National Partnership for Maternal Safety, an initiative aimed at reducing maternal morbidity and mortality, released a Consensus Bundle on Obstetric Hemorrhage, in conjunction with the Alliance for Innovation in Maternal Heath (AIM), which recommended that all hospitals that provide obstetrical care develop a standard treatment protocol for postpartum hemorrhage.5 The challenge for the smaller, often rural, hospital has been to determine what the protocol should be for a massive transfusion when their blood bank carries only a fraction of the blood products considered essential for most hemorrhage-treatment protocols. Lower-resource hospitals need site-specific protocols for managing the care of patients with massive hemorrhage. The tertiary care physicians who accept transfers of such patients should help identify resources available at the referring hospitals and partner with them to create such site-specific algorithms, including use of emergency-release blood, fresh frozen plasma, shock garments, and tranexamic acid. The workflow for patients requiring transport should be as efficient and seamless as possible.
Pregnant woman in rural communities cannot afford to lose access to local hospitals; rather, we need to make the care they receive as safe as possible. Team training and simulation of emergencies are common tools of the patient-safety movement, and electronic connectivity and broad implementation of a Maternal Health Compact are the next logical steps for improving patient care, retaining rural care facilities, and recruiting and supporting practitioners in the field.
Disclosure forms provided by the authors are available at NEJM.org.
This article was updated on April 6, 2017, at NEJM.org.
From the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston (S.M.); the Obstetric Service Line, Avera Health, Sioux Falls, SD (K.M.); the American College of Obstetrics and Gynecology, Washington, DC (H.B.); and the Duke University School of Medicine, Durham, NC (H.B.).
The Australian College of Rural and Remote Medicine (ACRRM), in recognition of its leadership and success in championing rural practice, is proud to have been invited by the WONCA Working Party on Rural Practice to host the 14th World Rural Health Conference to be held in Cairns from 29 April – 2 May 2017. This important conference will be held in collaboration with the 14th National Rural Health Conference from 26 – 29 April 2017, as part of A World of Rural Health.
The WONCA 14th World Rural Health Conference is an international event that will see delegates from around the world exchange information on the latest developments and challenges in rural family practice and rural and remote health generally.
The World Organisation of Family Doctors (WONCA) is a not-for-profit organisation with 118 member organisations in 131 countries and territories. The WONCA Working Party on Rural Practice consists of up to 20 members with representatives from each of the world’s regions: Europe, Asia, Africa, North America, South America, Australasia / Pacific.
The WONCA Working Party on Rural Practice vision is health for all rural people around the world.
The conference expects 900+ national and international delegates to attend. These will include rural doctors, researchers and academics, teachers, doctors-in-training, medical students, policy makers and administrators from both the public and private sectors.
The program will feature streams based on themes most relevant to all rural and remote health practitioners. These include Social and environmental determinants of health; Leadership, Education and Workforce; Social Accountability and Social Capital, and Rural Clinical Practices: people and services.
The extensive program will include a wide range of plenary sessions and workshops, and a number of excellent keynote speakers have already been confirmed. It also includes clinical sessions to provide skills development and ongoing professional development opportunities.
The World Summit on Rural Generalist Medicine is to be held as a pre-conference event, and potential delegates are welcome to participate in this important optional event.
Please email firstname.lastname@example.org for any detailed information required relevant to the WONCA 14th World Rural Health Conference in 2017 in Cairns.
A bursary fund exists for medical students, young doctors (in GP training program/Registrars/Resident – in first 5 years of GP practice) and doctors from developing countries, to assist with costs of attendance at the conference.