One of the most effective ways to reduce maternal and neonatal deaths is by encouraging women to give birth in health facilities with qualified health staff. But in provinces like Nusa Tenggara Timor (NTT) in Eastern Indonesia, well-built clinics offering space, privacy – or even running water – can be hard to come by.
Giving birth in a cramped, unlit room with other patients just outside the door has been the only option for countless mothers in NTT, contributing to many choosing unsafe deliveries at home without a trained midwife. And midwives and doctors have had to deliver babies in rooms with no running water and nowhere safe to discard medical waste.
But since 2012, the Australia Indonesia Partnership for Maternal and Neonatal Health program (AIPMNH) has built or renovated 24 maternity related units in health centres (puskesmas) and District Hospitals in 14 districts in the province, providing mothers and health staff with the facilities they need for clean, comfortable births.
“I didn’t feel comfortable at all when I gave birth to my first child at the puskesmas in 2011 - I was very concerned about my privacy,” said Ms. Ernestia Sulastri, 28. “The room was too small, and my husband had to go back and forth to my in-laws’ house to fetch the water needed during the birth.”
“Another post-partum mother was in the same room behind a curtain, and other general patients were very close to the birthing room,” she said. “I was in pain and feeling very uncomfortable at the same time.”
Ernestina was a patient at Golowelu puskesmas in Manggarai Barat district on the island of Flores, who later gave birth to her second child at the renovated health centre.
“With my second child, it was much better; the birthing room was big and clean, and I was able to recover comfortably in the post-partum room that had its own bathroom” she said. “The midwives and nurses also seemed to be working more comfortably and quickly, and the medicine and instruments were readily available in the room - my husband didn’t have to fetch water this time.”
Golowelu puskesmas, which provides health services for 14 villages and nearly 15,000 people, is one of the many health centres renovated through AIPMNH. By renovating/building maternity and neonatal units, waiting areas for pregnant women and their families, and providing clean water supplies to health centres, the program has ensured that health facilities have the adequate tools, infrastructure and equipment to support service delivery for hundreds of thousands of people in the province.
According to the Midwife Coordinator (BIKOR) at Golowelu, Ms. Ratna Edil Burga, the situation for both patients and staff has dramatically improved since renovations were completed in 2014.
Previously, the puskesmas only had one room, which was used for birthing, postpartum care and neonatal care, and was also crowded with boxes and buckets. But the biggest challenge was the lack of running water, which they would usually take from a nearby river - if they had time.
“It was difficult for us health workers to move quickly in such a small space,” she said. “But it’s all changed now.”
The clinic now has a separate room for birthing, post-partum care and a break room for midwives and nurses. Every room has its own basin with clean running water. As in other renovated puskesmas, a spool hoek (disposal system for liquid medical waste) has been installed. In the past, Golowelu would burn its medical and non-medical waste together behind the clinic, as is the norm for many health centres in NTT.
“These new facilities make us work better because we can move quickly and easily,” Ratna said. “We are much more comfortable attending deliveries.”
“And because of the neonatal care unit, we can save more babies,” she said. “Before this, we couldn’t take appropriate care for neonatal risks or complications.”
But how will the renovations of a puskesmas like Golowelu be maintained?
Operational budgets of health clinics are often small, so the puskesmas currently can’t rely on the district budget to maintain the new building.
Here is where the Puskemas Board for Health Services (BPKP) established through AIPMNH’s Community Engagement Program can come in, to advocate the community and local government to help maintain the clinic.
Mr. Marselinus Sius, Head of the Administrative Division for the puskesmas, explained that the newly established BPKP brings representatives from the puskesmas, the community, the District Health Office (DHO) and the village government together to discuss maintenance and possibilities for future funding from the district.
In fact, the Manggarai Barat DHO, one of AIPMNH’s main partners, already sees how the new facilities can serve as an example for future puskesmas.
“We are discussing the idea of involving the community through the BKPP in the maintenance of the puskesmas,” Dr. Ima said. “This is the best way to change people’s mindsets so they are aware that everyone has a responsibility to maintain the new maternal health building and water facilities.”
As for now, the staff checks regularly on the water pipe line running from the river. Puskesmas staff voluntarily donate a small fee to maintain the water pipe and pay for a cleaning service.
“I think the design is perfect for puskesmas with little land area,” said Dr. Imaculata (Ima) Djelulut. “Next year, we are planning to renovate two new puskesmas, and I want them to have rooms and a layout like Golowelu.”
Elsewhere on Flores, Puskesmas Waepana in Ngada district is having similar success.
Ms. Laurentia Dede, Midwife Coordinator for the puskesmas, described how the staff previously had to work in different rooms in different buildings while attending births. The room for antenatal care (ANC), birthing and post-partum treatment were all in separate buildings, and they would have to move women who had just given birth around, even while they were in pain.
“Imagine the risks of putting a newborn baby and birthing mother in the same room with other patients with other diseases,” she said. “Now, the rooms are in a nice, spacious building, and the layout allows us to work quickly and handle complications better than before.”
“And thanks to AIPMNH, now we can just turn on the tap and there is running water for 24 hours,” she said.
Head of Puskesmas Waepana, Ms. Margeretha Kroemn, is already thinking ahead about how to maintain the new clinic.
The puskesmas works through the BKPP to support regular maintenance of the new clinic, with 14 villages contributing 1 million rupiah/year (approximately 100 AUD/month) for a total of 14 million rupiah (approximately 1400 AUD/year). The puskesmas uses its existing operational budget to pay for cleaning.
However, Margeretha confirmed that funds from the district budget have been allocated for maintenance in the coming year, demonstrating the DHO’s interest and role in maintaining the newly renovated puskesmas.
Over on Timor island, the MNH Manager at Puskesmas Kaputu in Malaka district, Ms. Blandina Dahu, commented on patients’ satisfaction with the new puskesmas.
“One very helpful addition is the mother-friendly toilets. Every toilet has iron bars for handles so that pregnant and post-partum women can lift themselves,” she said. “Before, both men and women shared the same toilet.”
Similar to other renovated puskesmas, the staff is pooling its own resources together to maintain the clinic. Daily maintenance is shared between the midwives and nurses, and they have allocated a small portion of the jamkesmas (health insurance) budget to maintain the facilities.
While the efforts of the health staff at the renovated puskesmas are commendable, more resources will be required to maintain the health facilities. As the renovated facilities attract more pregnant women, local governments should see the benefit in allocating more funds to provide clean and comfortable birthing spaces to decrease the high maternal and neonatal mortality rates in NTT.
|Left to right: Ernestina Sulastri and her newborn, Midwife Ratna and Cantik (Ernestina first child). Ernestina gave birth to both of her children in Puskesmas Golowelu. She says giving birth was “much better” in the newly renovated puskesmas|
Left: Marsel Sius, Staff at Puskesmas Golowelu shows the running water used in the spool hoek in Puskemas Golowelu; Right: Yoseph Sudi, Head of Puskesmas Golowelu inside the VK room Puskesmas Golowelu
Before the renovations, the puskesmas had to fetch water from the river nearby or ask patients’ families to get it for them.
|Water tank tower and medical waste disposal system in the back of the new Maternity Building in Puskesmas Golowelu, Manggarai Barat. In the past, they would burn medical and non-medical waste in the open|
|Left: Spool Hoek. Right: toilet bowl and holding bar instead of the typical squat toilet to aid pregnant / post-partum women. All construction sites funded by AIPMNH have these kinds of toilets|
|Midwife Laurentia Dede, Midwife Coordinator, showing the Neonatal Care Unit in in Puskesmas Waepana, Ngada District|
|Laurentia Dede, Midwife Coordinator with her colleagues in Puskesmas Waepana, Ngada. Laurentia says they are able to handle complications much better now because of the new layout|
|Women waiting for different sort of services such as ANC, PNC, and KB (birth control) in Puskesmas Waepana, Ngada District. They said that they are happy because all services are now in one building and they can wait in the spacious, cool and clean waiting hall.|
Maternity Building (and water system) in Puskesmas Waepana, Ngada built by AIPMNH