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AN ANTENATAL RISK SCORING SYSTEM

East Java Safe Motherhood Study Probohnggo Distnct, East Java, IndonesIa

TEHCNICAL WORKING PAPER 2

January 1995

PoedJI RochJatl, MD, PhD PraJltno Prabowo, MD, PhD

Agus Abahdt, MD Benny Soeglanto, MD, MPH

Kresnayana Yahya, MSc

with

Barbara E Kwast, PhD, :MPH, MID MotherCare

The \1otherCare Project J ohn Sno~ lnc

I bib ~orth Fort Myer Dnve 11th Floor Arhngton V A 22209 USA

Report Prepared for the Untted States Agenc) for lnternatlonal Development

Office of Health Contract #DPE-5966-Z-OO-8083-OO

This publIcatIon was made possible through support by the Uruted States Agency for International Development Office of Health under the terms of

Contract DPE-5966-Z-8083-00, and John Snow, Inc

The contents of thiS document are those of the author(s) and do not necessanly reflect the views or polICies of USAID or lSIIMotherCare

LIST OF TABLES

TABLE 1 Demograph~c and Reproduct~ve Character~st~cs by Pre- and Post­survey Probol~nggo and Pasuruan, and R~sk Score Implementat1on, Probol~nggo East Java, 1992-1993 12

TABLE 2 Compar~son of R~sk Groups by Inclus~on of Tetanus Immun~zat~on Status ~n R~sk Score Implementat~on ~n Probol~nggo, 1992-1993 13

TABLE 3 Compar~son of R1Sk Groups by Pre- and Post-survey (Probol~nggo and Pasuruan) and Implementat~on (Probol~nggo), 1992-1993 15

TABLE 4 R1Sk factors ~n the Pre- and Post-survey and Implementat~on ~n Probol1nggo, 1992-1993 16

TABLE 5 R1Sk Factors by S1ng1e, Two, Three, and Four Occurrences 1n Probol1nggo, Implementat10n 1992-1993 (N=2S08/837S) 17

TABLE 6 Antenatal Care and Place of De11very by Pre- and Post-survey (Probol1nggo and Pasuruan) and Imp1ementat~on (Probol~nggo), East Java, 1992-1993 18

TABLE 7 Del1very Place and B~rth Attendant by R~sk Group for Pre- and Post-survey (Probol~nggo and Pasuruan), 1992-1993 20

TABLE 8 Del1very Place and B1rth Attendant by R1Sk Group for Implementat10n, Probo11nggo, 1992-1993 22

TABLE 9 Mode of De11very by R1Sk Group for Pre- and Post-survey (Probo11nggo and Pasuruan) and Implementat10n (Probol~nggo), 1992-1993 23

TABLE 10 Maternal and Per1natal Morta11ty for Pre- and Post-survey (Probo11nggo and Pasuruan) and Implementat~on (Probol~nggo), 1992-1993 24

TABLE 11 Compar1son of Proport10n of Maternal and Per1nata1 Mortal1ty w1th Proport1on of Del1ver1es by Place of B1rth for Pre- and Post-surveys Comb1ned (Probol1nggo and Pasuruan) 25

TABLE 12 Compar~son of Selected Character~st~cs between Screened and Unscreened Woman for the Post-survey, Probol~n990, 1992-1993 28

TABLE 13 Compar~son of Del~very Place and B~rth Attendant between Screened and Unscreened Women by R~sk Group for the Post-survey, Probol~n990, 1992 - 1993 29

TABLE 14 Soc~o-demo9raph~c Factors, Antenatal Care and R~sk Groups by Rural and Urban Areas for Post-survey 1n Probo11n990, 1992-199330

TABLE 15 Place of Del~very and B~rth Attendant by R1Sk Group 1n Rural and Urban Areas for Post-survey 1n Probo11D990, 1992 - 1993 32

TABLE 16 Compar1son of Per~natal Morta11ty by R1Sk Group and Screen1nq Status 1n Rural and Urban Probol~D990 (Post-survey) 1992 - 199333

LIST OF FIGURES

FIGURE 1

STUDY AREA SETTING PROBOLINGGO (RURAL & URBAN) AND PASURUAN (RURAL) AUGUST 1992 - JULy 1993

FIGURE 2

TIME TABLE OF PRE- AND POST-SURVEY (PROBOLINGGO AND PASURUAN),

3

AND PROBOLINGGO IMPLEMENTATION, JULy 1992 - AUGUST 1993 6

FIGURE 3

STANDARD GUIDANCE FOR IEC BY PKK 9

TABLE OF CONTENTS

Acknowledgements

1 INTRODUCTION 1

2 DESCRIPTION OF THE STUDY AREA 2

3 OBJECTIVES 4

4 METHODOLOGY 5

5 DATA ANALYSIS 10

6 RESULTS 10

7 DISCUSSION 33

8 CONCLUSION 37

Acknowledgements

Th~s study was carr~ed out by the Department of Obstetr~cs and Gynecology of the Dr Soetomo Hosp~tal, Med~cal Fac~l~ty, A~rLangga Un~vers~ty, Surabaya, East Java, Indones~a The proJect was supported techn~cally and f~nanc~ally by MotherCare ProJect, John Snow, Inc under contract tDPE 5966-Z-00-8083-00 w~th the U S Agency for Internat~onal Development, Sub-contract number 1659-0 30 A spec~al apprec~at~on ~s expressed to Dr M~ke L~nnan of CDC/Atlanta and USAID/Jakarta, for h~s expert adv~se on the study des~gn and h~s cont~nued support dur~ng the ~mplementat~on and analys~s of the Surabaya Safe Motherhood ProJect

The authors thank Dr Hur~p Sud~ro, Head D~str~ct Health Serv~ces, Dr Sanyoto Basuk~, Head Mun~c~pal Health Serv~ce Probol~nggo, Dr R I W~rJono, D~rector of Waluyo Jat~ Hosp~tal Dr L Soewarn~, D~rector Moch Saleh Hosp~tal, the Bupat~ of Probol~nggo D~str~ct, the Wal~kota of Probol~nggo Mun~c~pal~ty Camats the Heads of subd~str~ct, Doctors and m~dw~ves of Health centers, the Prov~nc~al, D~str~ct/Mun~c~pal~ty, and subd~str~ct Fam~ly Welfare Movement (PKK), Dr L~stya SetJal~lakusuma, Dr Slamet R~had~, Dr Achmad DJael~, Mrs Carolyn Hessler-Radelet and Ms Tut~k Murn~at~ for pat~ent typ~ng of proJect documents and results

MotherCare acknowledges the help of Dr Kathleen O'Rourke w~th the f~nal preparat~on of th~s work~ng paper

1 INTRODUCTION

The Republlc of lndonesla lS the world's largest archlpelago comprlslng 13,000 lslands and the fourth most populous country In the world lndoneSla has made remarkable progress In economlC development and ln the reductlon of lnfant and Chlld mortallty durlng the last two decades However, maternal mortallty rat lOS (MMR) are hlgh Wlth an estlmated natlonal average of 421/100 000 llve blrths, glvlng Indones~a the h~ghest level among The Assoclatl0n of Southeast ASlan Natl0ns Wlthln the country large varlatl0ns ln MMR eXlst ranglng from 360 ln Central Java to 1,340 In East Nusa Tenggara Across the country, 20,500 maternal deaths occur yearly The maJor causes of maternal death are hemorrhage (40%), sepsls (30%) and preeclampsla and eclampsla (20%)

The 1986 Natlonal Household Survey pOlnted out the magnltude of perlnatal deaths and neonatal deaths as contrlbutor to the lMR and as a contr~but~on to total mortallty Over one quarter of lnfant deaths were perlnatal More than half of these were attrlbuted to dlrect obstetrlc causes and a quarter due to growth retardatlon Thus, fully three quarters of perlnatal deaths were potentlally preventable wlth approprlate antenatal care, supervlsed asslstance at blrth and access to emergency obstetrlc serVlces

The lncrease In numbers of health centers and health sub­centers and lntegrated health posts (posyandu) at vlllage level has ~ncreased access to prenatal care to 80% of llve blrths (1) However accordlng to the Indonesla Demographlc and Health Survey only 56% have the 4 or more V1S1tS recommended by the Government of lndonesla (2) At dellvery, most women contlnue to be attended by tradltlonal blrth attendants (TBA) Nearly 68% of women flrst seek dellvery asslstance from TBAs and relatlves Mlaw~ves are the flrst asslstants sought for 58% of urban ael~verles and 18% of rural dellverles Doctors are the flrst asslstants called for only 2% of dellverles overall Overall, 79% of blrths take place at home wlth an rural - urban a~fferentlal of 90% and 49% respectlvely The GOl estlmates that only 30% of dlstrlct hospltals are able to provlde emergency obstetrlc serVlces and many women are unable to reach these fac_l_tles wlthln two hours of travel from thelr homes

Reduct~on of maternal and per~natal mortal~ty requlres comnun~ty based efforts wlth provlsl0n of baslc maternal and ch~la health serVlces and the development of an efflclent referral network for women who develop compllcatl0ns Even ~f an aaequate system were In place women and thelr famllles need to be conv_nced of the beneflt for uSlng a system WhlCh they cannot f_nanc_ally afford

IndoneSla has an effectlve women's network WhlCh lS called the PKK (Famlly Welfare Movement) The maln programs of the PKK

1

_nclude health promot~on, educat~on, household welfare and hone _naustry development Past act~v~t~es of th~s organ~zat_on have been effect~ve ~n br~ng~ng maternal ana ch~ld health serv_ces to the commun~ty through the posyandu Wh~le the PKK has been act_ve _n health care del~very, ~t has ma~nly been through soc_al Moblllzat~on efforts The PKK has not provlded d~rect hedlth serv~ces in the communlty

In 1989 a study was conducted _n S~doarJo d~str.ct _n East Java to _nvest~gate the posslblllty of us~ng rlsk based screen.ng by PKK In the commun~ty ~ost other stud_es of the use of r_sk­basea screenlng approaches have focused on lts use by health personnel In the S~doarJo study the PKK communlty volunteers were usee ~n partners hlP with the formal health system (3) The results showed that the system ach.eved success ~n tra.n_ng ~he communlty volunteers to lnteract With pregnant women The PKK runctloned well In the role of antenatal outreach worker as ev.denced by thelr success .n detect.on of r~sk factors ana classlflcatlon of the women appropr.ately ~nto r.sk groups The place and b~rth attendant appropr~ate to the level of care neeaea was planned between the PKK and the women As a result of the .nterventlon the need for emergency care was reducea and per~natal mortal~ty was lowered

Based on the pos~t~ve results of the S~doarJo pllot study the antenatal rlsk scorlng system was to be lmplemented .n a larger d~strlct In East Java, namely Probollnggo

2 DESCRIPTION OF THE STUDY AREA

Probollnggo Kabupaten (D~str~ct) sltuated 100 kID south of Surabaya ~n East Java, was the ~ntervent~on area The Kabupaten conslsts of 24 rural and 3 urban Kecametan (Sub-dlstrlctS) The total populat~on of Probollnggo ~s 1 077 561 (897,044 rural and 180 517 urban populatlon) The adJo~n~ng Kabupaten Pasuruan consist~ng of 24 sub-dlstrlcts, was used as comparlson area

These two dlstrlcts had geograph~cally d~stlnct strata wh~ch were recogn~zed as coastal, mldland and mounta~nous hlghlands In Probollnggo twelve sub-dlstrlcts (4 from each geograph~c stratum), one of wh~ch was an urban coastal area, were selected for the lmplementatlon of the rlsk scorlng system In Pasuruan s~x sub-dlstr~cts were selected (2 from each stratum)

F~gure 1 shows the populat~on for each sub- dlstr~ct, the number of hospltals, health centers, health staff, TBAs and PKK ava~lable for probollnggo and Pasuruan The total survey populat~on ~n Probollnggo was 544,748 and ~n Pasuruan 278,102

2

FIGURE 1

Sub Village district

PROBOLINGGO

Rural 11 151

Urban 1 11

TOTAL 12 162

PASURUAN

Rural 6 94

STUDY AREA SETTING PROBOLINGGO (RURAL & URBAN) AND PASURUAN (RURAL)

AUGUST 1992 - JULY 1993

PROVIDERS

Specialist

Population HC Hosp Ob/Gyn Pediat Health Midw1.ves Type C Center

Doctor

434,691 15 1 1 1 17 14

110,057 3 1 2 1 3 7

544,748 18 2 3 2 20 21

278,102 8 1 1 1 8 NK

3

NonHealth Personnel

Midwives TBA PKK Village

16 324 455

-- 29 47

16 353 502

NK NK N/A J

3 OBJECTIVES

The overall obJect~ve was to reduce maternal and per.natal nortal~ty through

3 1 Promot~ng the concept of potent.al r.sk .n pregnancy dnd awareness of the danger s~gns among pregnant women ana the_r fan.l.es by .mplementat.on of an antenatal r.sk scor_ng system

3 2 Improv~ng the network of matern~ty care as a cont_nuun l~nk~ng the commun.ty v.llage health post (Posyanaul v.llage b~rth~ng hut health center and hosp~tal and the appropr:ate use of matern_ty serv.ce

3 3 Involv.ng leaders .n the health sector and other relatea sectors ~n the East Java Safe ~otherhood Program of the Government of Indones.a

A To affect behav~or ~n the commun~ty

1 PKK Involve women health volunteers from the PKK _n the commun~ty to promote screen~ng and the detect:on of r~sk factors through door-to-door home v~s~ts to pregnant women Th~s was followed by IEe for antenatal care, referral once needed and plann~ng for the appropr~ate s~te and b~rth attendant

2 TBA Spec~f~c obJect~ves were to ~mprove the TBA's part~c~pat~on ~n the r~sk approach strategy for pregnant women through recogn~t~on of r~sk factors and a pos~t~ve response to the color code as a commun~cat~on tool for safe del~very

A second obJect~ve was to bu~ld good ~ntegrated teamwork between the PKK, the TBA and health personnel part~cularly m~dw~ves and health center doctors, as well as the hosp~tal

3 Women, Husband and Fam~ly Improve recogn~t~on of danger s~gns dur~ng pregnancy, del~very, and the postpartum/neonatal per~od w~th ~mproved health care seek~ng behav~or

Improve compl~ance w~th referral to a h~gher level of care when necessary

4

4 Communlcatlon Improve worklng relatlonshlps between the dlfferent levels of maternlty care responslble for safe dellvery

B To lmprove access serVlces In health lnstltutlon and In the health system overall

Improve tlmely referral of hlgh rlsk antenatal, lntranatal, and postnatal/neonatal bables

C To enhanclng pollcy dlalogue

1 Enhance the rlsk-based maternlty and neonatal care In the Government MCH Program

2 Enhance awareness and partlclpatlon of the other related sectors both governmental and non­governmental

4 METHODOLOGY

The communlty-based safe motherhood study was undertaken In two communltles In East Java Indonesla One communlty, Probol~nggo served as the lnterventlon communlty and the other, Pasuruan served as the comparlson The program conslsted of three components a pre-lnterventlon survey, an lnterventlon phase and a post-lnterventlon survey Pre and post-lnterventlon ~urveys were conducted In both lnterventlon and non-lnterventlon COMMun_t~es whlle the lnterventlon was conducted only In Probol~nggo

The pre-lnterventlon survey was admlnlstered In July 1992, _nnea_ately prlor to the lnterventlon The lnterventlon was conaucted from August 1992 to July 1993 The post-survey was ~cM_r_stered retrospect:vely over a 9 month~ lnterventlon perlod _r Vay 1993 whlle the .nterventlon was stlll contlnulng :aedlly the post-survey should have been conducted at the end of .2 Months lnterventlon Th.s could not be achleved because the proJect had to end contractually at the end of one year _~plenentatlon Flgure 2 presents a tlmellne for the proJect

5

FIGURE 2

TIME TABLE OF PRE- AND POST-SURVEY (PROBOLINGGO AND PASURUAN), AND PROBOLINGGO IMPLEMENTATION, JULY 1992 - AUGUST 1993

\<-------------- Probollnggo 1 1 1 1 1 1 , , ,

\-----\----_1 ___ '_--_'----_1----_1--_-, I

July August 1992 1992

Pre-survey Probollnggo Pasuruan

6

Implementatlon -------------->: , , I I I

--- --- ---, , ----- : ---- : , , May 1993

Post-survey Probollnggo Pasuruan

August 1993

4 1 Pre- and Post-survey

The Pre-Intervent10n Survey used structured quest10nna1res adm1n1stered by local paramed1cal personnel under the superv1s1on of graduate students from the Publ1c Health School of A1rlangga Un1vers1ty for the pre-survey and health personnel from the health center for the post-survey Health center phys1c1ans and m1dw1ves funct10ned as f1eld coord1nators Women were selected for the pre-survey 1f they had a pregnancy result1ng 1n ch1ldb1rth 1n the 12 months pr10r to the survey, and for the post-1ntervent10n survey 1f they had a ch1ldb1rth the pr10r 9 months (dur1ng the 1mplementat1on per10d) The quest1onna1re was retrospect1ve and women were asked about the1r prev10us obstetr1c and med1cal h1story Quest10ns were asked about the 1ndex pregnancy, ut111zat1on of health serV1ces, outcome of pregnancy, r1sk factors and compl1cat1ons, and recommended referrals, place of del1very and del1very attendant When women were not ava1lable for the surveys, another fam1ly member completed the 1nterv1ew

Sample S1ze the populat1on for the pre- and post-survey was 544,748 for Probol1nggo and 278,102 for Pasuruan Based on a nat10nal b1rth rate of 25 per 1000, the expected number of pregnant women 1n Probol1nggo was 12,500 and 6952 1n Pasuruan

4 2. Implementat10n of the home based Antenatal R1Sk Scor1ng System 1n Probol1nggo.

A copy of the antenatal r1sk score card 1S conta1ned 1n Append1x 1 The card was d1v1ded 1nto two sect10ns Part A and Part B Part A (Quest1ons 1-7) 1ncluded reproduct1ve markers such as age, par1ty, maternal he1ght, ch11d spac1ng, and obstetr1c h1story Part B 1ncluded emergency obstetr1c compl1cat1ons (bleed1ng and eclamps1a) (Quest1ons 8 and 9), and non-emergency med1cal and obstetr1c compl1cat1ons (Quest1on II), as well as tetanus 1rnmun1zat10n status (Quest10n 10) It was used only 1n the pregnancy per1od, compl1cat10ns dur1ng labor and del1very were not 1ncluded Pregnancy compl1cat1ons suspected by the PKK (Quest10ns 8, 9, 11) had to be conf1rmed by a m1dw1fe to be 1ncluded 1n the score

R1Sk scores were determ1ned by add1ng relevant numer1cal values ass1gned to reproduct1ve markers and obstetr1c comp11cat10ns The numer1ca1 values were based upon the relat1ve r1sk obta1ned 1n a per1nata1 mortal1ty study conducted 1n the Dr Soetomo Hosp1tal, Surabaya 1n the late 1980s (personal cornmun1cat1on, Dr Poed)1 Roch)at1)

From August 1992-July 1993, pregnant women were f1rst 1dent1f1ed by the PKK through the monthly cornmun1ty mother and ch1ld awareness group meet1ngs (KPKIA) wh1ch are attended by women, PKK, TBAs and m1dw1ves Pregnant women were subsequently

7

vlSlted at home and screened by a PKK, wlth results recorded on a score card A score was asslgned by a PKK durlng the flrst VlSlt and was updated durlng subsequent VlSltS If any compllcatlons occurred Scores were categorlzed accordlng to rlsk wlth 2-4 lndlcatlng low rlsk, 6-10 hlgh rlsk, and ~12 very hlgh rlsk The score card was deslgned so that all women recelved a mlnlmum score of 2 There are certaln reproductlve factors of the pregnant woman whlch contrlbute to the rlsk score but are not In themselves consldered rlsk factors, such as parlty 0 between 20 -29 years, and parlty I, II, III between 20 - 29 years The low rlsk group (score 2-4) comprlses only women w~th any of these relevant factors

Recommendatlons of the most appropriate place for dellvery and type of blrth attendant were then made based upon the women's scores A color code based on the total score at each Vlslt/contact was made by the PKK and attached at the front door of the woman's house Women at low rlsk were g~ven a green card and lnstructed that they could dellver at home attended by a tradltlonal blrth attendant Women at hlgh rlsk were glven a yellow card and lnstructed that they could only dellver at home If they were attended by a mldwlfe Otherwlse they were lnstructed to go to a health center for labor and dellvery Women at very hlgh rlsk were glven a red card and lnstructed to go to the hospltal for dellvery where they would be attended by elther a mldwlfe or a physlclan Flgure 3 shows gUldance for antenatal and dellvery referral

8

FIGURE 3

STANDARD GUIDANCE FOR IEC BY PKK

Total Risk Group Color ANC Referral 1n Del1very Score Code Pregnancy

S1te Attendant

2-4 Low R.lsk Green + No referral Mother's home TBA, m.ldW1fe

6-10 H.lgh Rl.sk Yellow + M.ldw.lfe, HC Home, M.ldw.lfe Poll.ndes, HC

12+ Very Hlgh Red + Hosp.ltal Hosp.ltal Doctor R1Sk

9

Data were prospect~vely collected dur~ng the ~ntervent_on per~od whlle data dur~ng the pre and post-~ntervent~on per_ods were retrospectlvely collected In addlt~on 72 1% of the ~omen who were ~nterv~ewed ~n the post-lnterventlon per.od had rece_ved a r.sk score card These women are ident~f.ed as screened and those who did not rece~ve the lntervent_on were ~dent.flea as unscreened Screened women were thus quest~oned about the pregnancy dur~ng wh~ch they were screened S~nce the _ntervent~on per~od cont_nuea for 12 months but the post-survey was conaucted ~n the lOth months after .mplementat~on the post­survey d~d not ~nclude all women who rece.ved the r.sk score card In add~t~on, women ~dent~f~ed dur.ng the post-survey coula not be l~nked ind~v~dually w~th the women having a risk score card dur~ng the ~nterventlon

However, the screened populat.on .dent.fled through t~e post-survey prov~ded the researchers w~th an opportun~ty to compare prospect~ve (dur~ng pregnancy) and retrospect.ve (pre­dnd post-survey) data Compar.sons between screened and unscreened women allowed ~dent.f_cat~on of dlfferences ~n the character~st~cs of women who rece~ved the lntervent.on and those who d~d not

5 DATA ANALYSIS

A Hewlett Packard computer was ~nstalled ~n the Ob/Gyn Department Inlt~al screen~ng of survey quest~onna~res and score cards was done ~n the f~eld Computer data entry was subsequently performed ~n Dr Soetomo Hosp~tal followed by further data clean~ng SPSS 4 software was used for quant.tat.ve analys~s us~ng blvar~ate and mult~varlate techn~ques

Results are presented w~thout stat~st~cal tests of assoc~at~on as the study ~nvolved a populat~on-based survey and there ~s no approXlmatlon from a sample In add~t~on calculat~ons based upon complete analyses would appear to be statlst~cally s~gnlflcant s~mply because of large cell s~zes and would not necessarlly reflect a pract~cal s~gn~f~cance Therefore, results are ~nterpreted based upon practlcal d_fferences

6 RESULTS

6 1 Basel~ne Compar1sons

The total number of respondents dur~ng the pre-survey per~od was 9373 ~n Probollnggo and 6447 In Pasuruan Dur~ng the post­survey WhlCh was retrospectlve over a 9 months perlod, 7101 women were lntervlewed In Probollnggo and 4753 In Pasuruan Durlng the 12 months lmplementation period in probolinggo, 8457 pregnant women were identified of WhiCh 82 had a miscarrlage

The rlsk score card was analyzed for 8375 screened women Theoretlcally women questioned durlng the post-survey ~n

10

Probol~nggo would be the same women who had rece~ved the score card dur~ng the f~rst 9 months of the ~mplementat~on per~od Further analys~s of the same 9 months per~od covered by the post­survey and ~mplementat~on shows that 7049 women w~th an antenatal r~sk score card gave b~rth wh~le a total of 7101 del~vered women were ~dent~f~ed ~n the post-survey -- a d~fference of 0 8% However, 5127/7101 (72 1%) women ~n the post-survey stated that they were screened w~th a score card Two explanat~ons are poss~ble E~ther the quest~on regard~ng screen~ng was m~sunderstood by the women ~n the post-survey or, ~ndeed, the post-survey had an underreport~ng of 27 3% compared to the number captured ~n the ~mplementat~on (5127 women versus 7049) There were no proport~onal d~fferences ~n underreport~ng between urban and rural areas Val~dat~on of data allover the world show some degree of underreport~ng ~n survey data and ~t ~s reasonable to assume that a proport~on of women w~ll have been m~ssed ~n both ~mplementat~on and post-survey It ~s unl~kely that almost one th~rd of the pregnant women were m~ssed ~n the ~mplementat~on of the r~sk score card As the data of the post-survey and ~mplementat~on were never l~nked, the f~nal answer to th~s d~screpancy w~ll rema~n ~nconclus~ve

Demograph~c and Reproduct~ve Character~st~cs

The age d~str~but~on, par~ty, educat~onal level, spousal educat~on, and spousal employment character~st~cs of the surveyed women ~n Probol~nggo, Pasuruan, and the ~mplementat~on area (Probol~nggo) are presented ~n Table 1 Compar~sons are subd~v~ded ~nto pre and post-survey per~ods for Probol~nggo and Pasuruan

Overall there were m~n~mal d~fferences regard~ng age and par~ty d~str~but~on between pre- and post-survey per~ods for both Probol~nggo and Pasuruan (Table 1) The educat~onal levels of both pregnant women and husbands showed marked d~fferences between the two areas ~n the categor~es <4 years

In general there were some notable d~fferences between Probo1~nggo and Pasuruan There was a greater prevalence of pregnant women <20 years ~n Probol~nggo as compared w~th Pasuruan In Pasuruan, there were a greater number of women who were par~ty ~ 5 Maternal educat~onal level appears to vary greatly ~n all groups, espec~ally ~n the lower educat~onal levels (0-3)

There was also a great var~at~on between the Probol~nggo post-survey results and the ~mplementat~on per~od and ~t ~s l~kely that much of th~s d~fference results from a report~ng b~a5 A s~m~lar pattern ~5 noted ~n the de5cr~pt~on of husbands' educat~on

The analy5~s of maternal occupat~on ~s less mean~ngful as most women ~dent~f~ed themselves as housew~ves even ~f they spent a s~gn~f~cant proport~on of the~r t~me ~nvolved ~n other econom~c

11

TABLE 1

---

Demograph~c and Reproduct~ve Character~st~cs by Pre- and Probo11nggo and Pasuruan, and R1Sk Score Implementat10n,

East Java, 1992-1993

Post-survey Probo11nggo

Probollnggo Survey Pasuruan Survey

Pre Post Pre Post N=9373 N=7107 N=6447 N=4753

n \ n \ n \ n \

Age (years)

<16 214 2 3 135 1 9 47 0 7 lO 0 5 17-19 1509 16 1 1202 16 9 55.! 8 6 479 10 1 20-34 6853 73 1 5238 73 7 5159 80 0 3803 80 0 :;:35 797 8 5 532 7 5 689 10 7 44') 9 4

Parlty

0 4110 43 8 3 1 1 1 43 8 3004 4b 7 1 H4 7 38 9 1 2512 26 8 2051 28 8 1364 II 1 lU9 l'-. 9 2 1366 14 6 1028 14 5 858 1 ] 3 71 J 15 0 3 656 7 0 471 6 6 45.! 1 0 .; \J I 8 0\ 4 361 3 9 214 3 0 ]0] .; 7 ,OJ 4 3 >5 368 3 9 232 3 3 4&6 7 J HI) 7 b

Educatlon of Pregnant Woman (years)

0 1266 13 ') 805 1 1 1 'd.:' 1 '1 II ) 1 tI V

<4 1301 13 9 1669 23 '> 1714 lb 7 1 Ill .. III )

4-6 499') 53 3 1144 H 3 3'>11 '>4 1 I ...... , .; 1 .., 7-9 792 8 4 ob8 9 4 367 '> ) • 7 b '> !j

10-12 907 9 1 70b 9 9 l.ll '> u • -l 1 -, 1 >12 ILl 1 l. II '> 1 b 0 I) , ) LJ '>

Educatlon of Husband (years)

0 ll06 Il. 9 80') 9 5 364 '> b '>'}oj Ll '> <4 912 9 7 1669 olD ') 1.14.l 19 1 I 1 '>-l H 1 4-6 4657 49 7 3144 40 5 3829 ')9 4 oll b 1 4'> '> 7-9 986 10 5 668 10 7 49£1 7 7 4n 8 9 10-12 1381 14 7 706 16 1 Cd 6 8 0 Pb 7 9 >12 231 2 5 1 1 ') .l 7 0 0 41 0 9

Occupatlon of Husband

Laborer 4U') 4'> 1 3 III J H 11 ltd ':I '>b '> I h .. I )

farmer .!535 27 0 l09Ll 19 .; 17 III lb , II I t

flsher 853 9 1 'h 1 1 0 I I

Merchant 987 10 5 '>bO 7 9 '> III Il \I 11 I

Gov Employee 493 5 3 1031 I .. '> 017'> I .. J 1 .. UnspecIfIed Job l80 3 0 101 9 l I lull I I I ~ 1 ..

Probollnggo I

Implementatlon ,

I

N=8375 I n \

I

i

163 l 0 1474 17 0 6108 H 1

')30 6 3

!

3838 4'> 8 H73 19 ') lib 1 13 9

483 '-. 8 117 1 0

I lOl 1 01

I

bllt> ~ .:' 'l Il l 7

I I b ' bll 8 114u Iv 0 7th '1 4

7t> u ':I

'>81 b 9 189 .l j

"1111 b J 4 914 II ,

lUI 14 0 139 I 6

It I j ..

J J H J . 'I "'t

.. , 'i b

I H I J I I J

- - -- - -- - ---------

BEST AVAILABLE COpy ,a,

actlvltles (data not presented) Husbands' occupatlon appears to be falrly evenly dlstrlbuted, wlth 60-70% of husbands employed as laborers and farmers Agaln, there were dlfferences In the recordlng of husbands' occupatlon between the Probollnggo post­survey and the Probollnggo lmplementatlon perlod

6 2 R~sk Groups

RlSk groups were ldentlfled durlng the Probollnggo lmplementatlon per~od The d~str~but~on of r~sk groups was as follows low rlsk 69 1%, hlgh rlsk 29 2%, and very h~gh r~sk 1 7%

One of the rlsk factors ldentlfled was lack of maternal tetanus lmmunlzatlon Thls rlsk factor contrlbuted greatly to the categorlzatlon of women as hlgh" and "very hlgh rlsk" Consequently rlsk groups were constructed In the data analysls wlthout the varlable measurlng maternal tetanus lmmunlzatlon status Table 2 presents the results of rlsk scorlng wlth and wlthout tetanus lmmunlzatlon status It lS apparent that wlth the lncluslon of a varlable measurlng tetanus lmmunlzatlon status there lS a hlgher percentage of women In the "hlgh" and very hlgh rlsk categorles

TABLE 2

Compar1son of R1Sk Groups by Inclus10n of Tetanus Immun~zat~on Status 1n R1Sk Score Implementat10n 1n Probol~nggo, 1992-1993

Tetanus Immun1zat1on (none)

R1Sk Group Included Not-Included Total Score N=8375 N=8375

n % n %

Low RlSk 2-4 5788 69 1 6523 77 9 Hlgh RlSk 6-10 2447 29 2 1792 21 4 Very Hlgh RlSk ~12 140 1 7 60 0 7

PKKs together wlth a mldwlfe lncreased the score on the score cards If compllcat.ons occurred durlng the pregnancy WhlCh were conflrmed by a mldw.fe or doctor (scores never decreased, they could only lncrease over the tlme of pregnancy) However scores were seldom revlsed For 92 9% of the women there was no change .n thelr total score whlle 6 1% changed once and 1% changed more than once When tetanus lmmunlzatlon status was not _ncluaed .n the determlnat.on of rlsk groups, the score was changed less frequently (96 7~ dld not change)

PKKs vlslted the maJorlty of women regularly throughout the_r pregnancles Only 7 3% of all women had thelr last v~s~t pr.or to the 8th month 17 6% had thelr last VlSlt durlng the 8th month and 75 1% of women were seen lnto the 9th month of pregnancy Thus the lack of change In score was not due to cessat_on of VlSltS by the PKKs but rather because of non-

13

recogn~t~on of compl~cat~ons by PKKs on h.story tak~ng only Women a~d not keep the score cara and thus could not take these to antenatal exam~nat~ons by a m~dw~fe or doctor Even ~f t~e woman was d~agnosed w~th a compl~cat~on she nay not have reported thls to the PKK

Changes from pre to post-survey per~ods _n the class_f_cat~on of women by r~sk status Nere evaluated ~n the ~ntervent~on and non-~ntervent~on connun~t_es (Table 3) Unless otherWlse lnd~cated a var~able neasur_ng tetanus .mmun_zat_on status was _ncluded ~n the construct~on of rlsk score

The h~ghest percentage of wonen _n all groups were categorlzed as Low R1Sk Fewer Nonen Nere categor_zea as H~~~ R_sk and Very H~gh R~sk ~n the ~Mplenentatlon area There ~as d markea change 1n r_sk score anong the ~_gh r~sk groups fron t~e pre- to post-survey per_od ~n Probol_nggo whlle there was less change ~n Pasuruan To _dent_fy the reason for these changes the d_str_but10n of spec~f_c r_sk factors was evaluated .n Probol~nggo for the pre- and post-survey perlods as well as for the _mplementat~on per~od (Table 4) Data are not presented for Pasuruan Slnce llttle change 1n r_sk groups occurred Compl_cat_ons presented were not mutually excluslve so that wonen could be 1ncluded ~n more than one category

The most common r~sk factor noted was non-compl~ance w~th tetanus lmmunlzatlon and th~s lncreased from 15 7% of women 1n the pre-survey perlod to 28 3% dur~ng the post-survey perlod (Table 4) In addltlon there were d~fferences ~n var~ables of ch~ld spac~ng, poor obstetrlcal h_story h~story of a d~fflcult blrth and prevlous cesarean-sect_on

To determ~ne how women were ass_gned to r1sk group1ngs the number and type of 1dent1f1ed rlsk factors was analyzed for each _nd1v~dual woman 1n the Probol1nggo Implementat10n Area Table 5 shows a breakdown of the 30% of women (2508/8375) who had e1ther one two three or four r1sk factors the rema1n1ng women d1d not have markers Wh1Ch were cons~dered r~sk factors

Th1rty-f1ve percent of women who would have been low r1sk were placed 1n the h1gh r1sk categorles only because they d~d not have tetanus ~mmun1zat~on (TT) F1fty-seven percent of women w1th a slngle r1sk factor had only a reproduct1ve r1sk factor wh1le 7 6% 1n the slngle r1sk factor category had an obstetrlc compl1cat1on

The total number of women who had one or more obstetr1c compl1cat1ons dur1ng pregnancy was 3 5% (292/8375), regardless of whether these were assoc1ated w1th e1ther lack of TT or any reproduct1ve markers N1neteen percent of women (1547/8375) had a reproduct1ve r1sk factor wlth or w1thout other obstetrlc compllcat1ons and no TT Tables 1 to 11 ~n Append~x 2 provlde a more deta~led descr1pt1on of the contrlbutlon of lnd~v1dual rlsk factors to the rlsk score These tables were categorlzed accordlng to urban and rural settlngs so that dlfferences by type of commun1ty could be ldentlf~ed

14

TABLE 3

Comparlson of Risk Groups by Pre- and Post-survey (Probollnggo and Pasuruan) and Imp1ementatlon (Probo11nggO), 1992-1993

~- --~ ------- ~~ -- ~--

Probolinggo probolinggo Survey Pasuruan Survey Implementation

Pre Post Pre Post Rhk Group N=9373 N=7101 N=6447 N=4753 N=8375

n \ n \ n \ n \ n \

I ow R 15k ('} - ~ I ~~87 ~8 OJ 39 7 OJ 55 9 4178 64 8 2858 60 1 5788 69 1

II1gh Rl'lk (6-10) '} 81 7 30 1 2803 39 5 1901 29 5 174 1 36 6 2447 29 2

I Very IIlgh Risk (>12) 1069 1 1 4 329 4 6 368 5 7 154 3 2 140 1 7

15

TABLE 4

R1Sk factors 1n the Pre- and Post-survey and Implementat10n 1n Probo11nggo, 1992-1993

I PROBOLINGGO I Pre-survey Post-survey ImplementatIon

Total b1rths N=9373 N=7107 N=8375

Total women 1n groups I, II, III n=7520 80 2% n=4640 65 4% n=3614 43 1%

% of % of % of R1Sk factors by group n total n total n total

GROUP I 5264 56 16 2196 30 89 2277 27 10

Young prlmi gravIda 214 2 28 13~ 1 89 1 1 5 1 40 Elderly primi gravIda 498 5 31 120 1 69 62 0 70 Grand multIpara 449 4 79 446 6 27 <121 5 00 Over 35 years 797 8 50 532 7 49 530 6 30 Youngest Chlld < 2 years 631 6 70 190 2 67 384 4 60 Youngest Chlld ~ 10 years 827 8 80 335 4 71 347 4 10 Low helght ~ 145 cm 92 1 00 73 1 00 1 2 1 1 15 Poor obstetrIC hIstory 837 8 93 316 4 44 268 3 20 Hlstory of dIfflcult bIrth 434 4 67 33 o 40 20 o 20 Prl0r cesarean sectl0n 385 4 11 16 o 30 9 0 10

GROUP II 200 2 13 83 1 1 7 39 o ~o

Bleedlng 177 1 80 56 0 79 35 o 40 EclampSIa 23 0 20 1 7 o 24 4 0 10

GROUP III 2056 21 94 2361 33 20 1298 15 49

MedIcal condItIon 96 1 00 49 o 69 64 o 70 PreeclampsIa 107 1 10 55 0 77 49 o 60 MalpresentatIon 92 0 90 83 1 1 1 65 0 10 TWIn pregnancy 80 0 50 28 0 39 39 o '>0 Hydramnion 15 0 10 1 3 0 18 6 0 10 IUFD 39 0 40 30 o 40 26 0 30 Post-dates 152 1 60 88 1 24 30 0 10 TT lmmunlzation 1475 1 ~ 70 2015 28 33 1 I) 1 9 12 LO

16

TABLE 5

RISk Factors by SIngle, Two, Three, and Four Occurrences 1n Probol1nggo, Implementatl0n 1992-199] (N=250S/S]75)

Occurrences

Single Two Three Four N=2141 25 6\ N=26 3 9% N=36 o 5% N=5 o 06%

\ of \ of % of % of I Variable n group n group n group n group

Reproduct1ve only 1226 57 3 N/A N/A N/A ObstetrIc compl1cat1on only 162 7 6 N/A N/A N/A No TT only 753 35 2 N/A N/A N/A

No TT + reproductIve factors N/A 181 55 5 N/A N/A No TT + one obstetr1c complication N/A 27 8 3 N/A N/A One reproductlve factor N/A 44 13 5 N/A N/A Reproductlve + one obstetrlc

compllcatlon N/A 64 19 6 N/A N/A Two obstetrIc compilcations only N/A 10 3 1 N/A N/A

No TT + two reproductIve factors N/A N/A 11 30 5 N/A No TT + one reproductIve factor +

one obstetrIc complIcatIon N/A N/A 11 30 5 N/A Two reproductIve factors + one

obstetrIc complIcatIon N/A N/A 3 8 3 N/A One reproductIve factor + two

obstetrIc complIcatIons N/A N/A 6 16 7 N/A i

Three reproductIve rIsks N/A N/A 3 8 3 N/A Three obstetrIc complIcatIons N/A N/A 1 2 8

No TT + one reproductIve factor + 2 obstetrIc complIcatIons N/A N/A 4 80 0

Two reproductIve factors + two obstetrIc complIcatIons N/A N/A N/A 1 20 0

17

TABLE 6

Antenatal Care and Place of Del~very by Pre- and Post-survey (Probo11nggo and Pasuruan) and Implementat~on (Probo11nggo), East Java, 1992-1993

Probo11nggo Survey Pasuruan Survey place of ABC and Dell.very Pre Post Pre

N=9373 N=7101 N=6447 n % n % n %

ABC

Health Facl.ll.ty 5472 70 4 5319 71 3 5242 79 9 Posyandu 836 12 6 1087 17 6 Polindes n/k 230 3 5 379 7 3 HC 4064 72 6 3257 68 7 n/k HOspItal 472 14 8 475 10 2 3394 64 1 Prl.vate mIdwIfe N/A N/A 1469 21:1 0 Pr~vate doctor N/A N/A N/A

Other (none or 2576 28 3 1788 29 3 N/A TBA) 1205 18 6

Place of Del~very Home 8028 86 0 6018 83 6 5626 87 3 Polindes 15 o 1 12 o 2 34 o 5 HC 1 15 1 2 113 1 6 1 12 1 8 HospItal 1215 12 7 966 14 7 675 10 4

* Not mutually exclusIve Some patIents attended more than one faCIlIty ** Data not avaIlable for pre and post-surveys

18

Post N=8375

n %

3886 81 8 598 15 4 108 2 8

2978 76 6 202 5 3

N/A N/A

18 2

4044 85 0 32 0 I

102 2 2 575 12 1

Probo11nggo Implementat10n

N=8375 !

n %

6620 79 0 I

2352 35 5 16 o 2

I

2317 35 0 I 173 2 6

1583 24 0 179 2 7

1775 21 0

7152 85 4 109 1 3 51 -t 6 1 600 7 2

6 3 Use of Matern1ty Serv1ces

Antenatal care could be performed ~n the posyandu, pol~ndes (v~llage b~rth~ng hut), the health center, or the hosp~tal In add~t~on,places for ch~ldb~rth ~ncluded the women's or m~dw~ves' homes, the pol~ndes, the health center, and the hosp~tal

Table 6 presents the d~str~but~on of antenatal care and place of b~rth ~n Probol~nggo and Pasuruan (pre and post) as well as ~n the ~mplementat~on area In general more women rece~ved antenatal care ~n Pasuruan than ~n Probol~nggo (80% vs 70%, respect~vely) There appears to be a d~fference ~n the antenatal care prov~ded ~n health center and hosp~tal when the Probol~nggo post-survey per~od and the ~mplementat~on areas are comparee Compar~son of the pre- and post-surveys showed a s~gn_f~cant reduct~on ~n hosp~tal-based antenatal care ~n Pasuruan

Approx~mately 85% of all del~ver~es occurred ~n the horne ~n all areas There ~s a dlfference ~n the recordlng of hosp~tal as a place of del~very when Probol~nggo post-survey and lmplementat~on per~od are compared

Tables 7 to 9 present women by r~sk groups relat~ve to the~r place of del~very and b~rth attendant, and mode of del~very Analyses are presented for all three areas Probol~nggo and Pasuruan (pre- and post-survey> (Table 7) and the ~mplementat~on area (Table 8)

As stated above most del~ver~es occurred at home Wh~le ~n general more Very H~gh R~sk women del~vered ~n the hosp~tal, c_fferences are qu~te small and the maJor~ty of these women st~ll eel_verea ~n the horne (Tables 7 and 8) S~mllarly, the vast naJor_ty of del~ver~es were attended by TBAs There ~s no change between pre- and nost-survey and thus no program effect

Dur~ng the ~mplementat~on per~od, recornrnendat~ons were g~ven to the women concern.ng appropr~ate place of del~very and eel_very attendant These recornrnendat~ons were based on the r~sk score as descr~bed .n the methodology The cross tabulat~ons of the place of del~very and blrth attendant by r~sk group prov~de a clear p.cture of m~nlmal compllance wlth recornrnendat~ons (Table 8 )

19

TABLE 7

I

I I

I

Del~very Place and B~rth Attendant by R~sk Group for Pre- and Post-survey (Probol~nggo and Pasuruan), 1992-1993

------- - ~- - -- ... - --~- ------ ---- --- ---- --

probo1~nggo Survey

Placel Pre (N=93731 Post (N=7107) Attendant Low R1Sk Hlgh R1Sk Very Hlgh R1Sk Low RISk HIgh RISk Very HIgh RISk

N=5487 N=2817 N=1069 N=3975 N=2803 N=329

n % n % n % n % n % n %

Home 4688 85 4 2450 87 0 890 63 3 3248 81 7 2496 89 0 2/4 83 3

TBA 3958 84 4 2537 87 2 764 85 8 2602 80 1 2240 89 7 249 90 9 Mldwlfe 730 15 6 313 12 8 126 14 2 646 19 9 256 1 0 3 25 9 1 Doctor 0 a 0 a 0 -

Health Center 88 1 6 30 1 1 12 1 1 80 2 0 39 1 4 6 1 8

Mldwife 88 100 a 30 100 0 12 100 a 80 100 0 39 100 0 6 100 0 Doctor 0 0 0 0 0 0

Hospltal 711 13 0 337 11 9 167 15 6 657 16 3 268 9 6 49 14 9

Mldwlfe 527 74 1 212 62 9 72 43 1 472 72 9 162 60 4 25 51 0 Doctor 184 25 9 125 37 1 95 56 9 175 27 1 106 39 6 24 49 0

20

TABLE 7 (cont d )

Pasuruan Survey

Placel Pre (N=6447) Post (N=4753) Attendant Low RISk HIgh RISk very Hlgh RlSk Low RlSk Hlgh Rlsk Very Hlgh Rlsk

N=4178 N=1901 N=J68 N=2855 N=1741 N=154

n \ n " n " n % n % n %

Home )~q7 R6 I 1 7 1 7 90 J J 1 2 84 8 2))) 81 6 1589 9 1 3 122 79 2

T8A "q~J R1 I ISH 89 6 271 86 9 1898 81 4 1454 9 1 5 106 86 3 Mldwlfe 641 1 7 8 I 78 10 4 4 1 1 J 1 434 18 6 135 8 5 1 6 1 3 1 Doctor ) 0 1 - - 1 o 0 - -

Health Center 1 12 2 7 18 I S 6 1 6 104 3 7 26 1 5 4 2 6

Mldwlfe 1 1 1 99 1 26 92 9 6 100 0 103 99 0 26 100 0 1 25 0 Doctor 1 o 9 2 7 1 - 1 10 0 - 3 75 0

Hospltal 469 1 1 2 156 8 2 50 13 6 421 14 7 126 7 2 28 18 2

Mldwlfe 395 84 2 111 71 2 15 30 0 369 87 6 78 61 9 14 50 0 Doctor 74 15 8 45 28 8 35 70 0 52 12 4 48 38 1 14 50 0

21

TABLE 8

Del~very Place and B~rth Attendant by R~sk Group for Implementat~on, Probol~n990, 1992-1993

Low Rl.sk Hl.qh Rl.sk Very Hl.gh R1.5k Place/Attendant N=5788 H=2447 H=140

n \ n \ n \

Home 4908 84 8 2144 87 6 101 72 2

TBA 4152 84 6 .835 85 6 85 ~"t J .. M~dw~fe 756 .5 . 309 .4 4 !6 ) 8 .. Joctor 0 0 .J 0 0 0

Health Center 475 8 2 139 5 7 10 7 1

M~dw~fe 385 8 : 0 06 ~6 3 5 50 0 Doctor 90 .9 0 33 23

~ 5 SO J

Hospl.tal 405 7 0 164 6 7 29 20 7

M~dw~fe 292 72 2 ~9 47 9 8 27 6 Doctor 113 27 8 85 52 1 21 72 4

Although the Very H~gh R~sk women were ~nstructed to del~ver ~n the hosp~tal, 72% of these women del~vered at home

I

I

I

I

I I

I I , I

Of these del~ver~es 84% were attended by a TBA (Table 8) The H~gh R~sk women were ~nstructed to e~ther del~ver ~n the health

center or home attended by a m~dw~fe However, 75% 0 these women del~vered at home attended by a TBA

The mode of del~very d~d not d~ffer markedly between r_sk groups as overall cesarean sect~on rates are extremely low rang~ng from less than 1% for the Low R1Sk group to 5% for the

Very H~gh R~sk" groups (Table 9) There 1S a marked d~fference between the recorded cesarean sect~on rate dur~ng the _mplementat~on per~od (8 6%) and all other perlods (Pasuruan pre-survey = 2 7%, post-survey = 5 2% Probol~nggo pre-survey = 2 0% post-survey = 2 5%)

22

TABLE 9

Mode of Delivery by Risk Group for Pre- and Post-survey (Probo11nggo and Pasuruan) and Imp1ementatlon (Probollnggo), 1992-1993

----

Probolinggo Survey Pasuruan Survey Probolinggo Implementat~on

Pre Post Pre Post N=9373 N=7107 N=6447 N==4753 N=8375

n \ n \ n \ n \ n %

Spontanrnuq Vaginal 911:16 91:1 6 6914 97 1 6361 91:1 7 4636 97 5 8226 98 2 Oprratlvr vaqlnal I 1 J 1 2 1 ) 2 2 0 48 o 7 79 1 7 85 1 0 Caesar ran <;rc t Ion 14 o 1:1 6 I o 9 38 o 6 38 0 8 64 o 8

Low Risk Spontanrous Vaginal ')423 98 8 3887 97 7 4133 98 9 2800 98 0 5726 98 7 Oprrativr Vaginal 41 o 8 63 1 9 27 o 7 43 1 5 40 o 8 Caesarran Section 23 o 4 25 o 3 18 o 4 15 o 5 22 o 6

High Risk Spontanrous Vaginal 2759 97 9 2716 97 9 1878 98 8 1694 97 3 2382 97 7 Operative Vaginal 31 1 1 58 2 1 14 o 8 32 1 8 35 1 3 Caesarean Section 28 1 0 29 1 0 9 o 4 15 o 9 30 1 1

Very High Risk Spontaneous Vaginal 1005 94 2 311 94 0 352 95 5 142 92 2 118 84 3 Operative Vaginal 41 3 8 11 3 6 7 1 7 4 2 6 10 7 1 Caesarean Section 23 2 0 7 2 5 11 2 8 8 5 2 12 8 6

Percentages are calculated out of each r1sk group as g1ven 1n Table 7

23

6 4 Maternal and Per1natal Morta11ty

~aternal and per~natal mortal~ty rat~os were calculatea for the three study per~ods (Table 10) The reported nuMbers of maternal deaths ~n Probol~nggo and Pasuruan were relat.Jely :ow w~th 35 deaths/IS 955 b~rths ~n the pre-survey per~ods ~O

aeaths/ll,917 blrths 1n the post-survey per~oas and 26 aeaths/8,4lS blrths dur~ng the lmple~entat~on perlod Vaternal death rat~os were also calculated for the d.fferent r.sk qroups In the post-survey perlod, maternal Mortal.ty .ncreased .n the

Low and H~gh R1Sk groups but decreased from the Very H.gh R1Sk group Whlle maternal mortal.ty rat~os rose wlth .ncreasea r.sk the small numbers of maternal aeaths make these est.~ates unstable

Per~natal mortallty rat.os were also calculated ana there _~ conslstent eVldence that per.natal Mortal.ty rat.os .ncreasea d~ r.sk category ~ncreased In add~t.on there was a cons.stent .ncrease .n reported per~natal mortal.ty for the post-survey perlod .n both areas for all r~sk groups Per~natal mortal.ty was a more common outcome w.th 361 aeaths!15 955 b1rths .n the pre-~nterventlon perlod 250 deaths!11 917 b1rths .n the post­_ntervent~on per~od and 363 deaths!8415 b~rths dur.ng the .~plementat~on A more detalled breakdown of maternal and perlnatal mortal~ty by rlsk group 1S presented 1n Appena1x 3 Tables 1 and 2

TABLE 10

Maternal and Per~natal Mortal~ty for Pre- and Post-survey (Probo11nggo and Pasuruan) and Implementat10n (Probo11nggo),

1992-1993

Proboll.nggo Pasuruan Survey Survey

Pre Post Pre Post

Maternal Mortall.ty 268 5 373 9 155 3 297 (MMR)

Perl.natal Mortall.ty 27 1 41 5 ... 6 1 23 (PMR)

MMR Low R~sk 238 8 291 3 96 3 211 Hl.gh Rl.sk 177 4 468 3 104 3 415 Very Hl.gh Rl.sk 667 9 441 3 1084 2 763

PMR Low Rl.sk 17 3 23 9 10 3 12 Hl.gh R~sk 29 3 55 0 20 6 31 Very H~gh R~sk 69 9 139 4 57 3 115

Maternal Mortall.ty Rat10/100,OOO ll.ve bl.rths Perl.natal Mortall.ty Ratl.o/lOOO total bl.rths

24

Probo1l.nggo Implementatl.on

6 316 5

a 43 1

4 157 6 9 503 4 9 4166 7

3 29 5 8 63 9 2 194 2

The comblned total number of blrths, maternal deaths, and perlnatal deaths were obtalned for Probollnggo and Pasuruan durlng both survey perlods Percent of maternal and perlnatal deaths were compared wlth the percent of blrths by place (home, hospltal, other) to determlne If a dlsproportlonate number of deaths occurred In a partlcular settlng (Table 11) Results showed that there was a correlatlon between percent maternal and perlnatal mortallty and percent of blrth place categorles Thus, It does not appear that a dlsproportlonate number of deaths occurred In a partlcular settlng

The purpose of the lmplementatlon of the screenlng tool was to ~dentlfy rlsk factors whlch could lead to an adverse pregnancy outcome As the lnterventlon dld not lnclude recordlng of compllcatlons durlng labor and dellvery or the lmrnedlate postnatal perlod, the efflcacy of the pregnancy screenlng tool could only be tested for perlnatal and maternal mortallty Consequently the sensltlvlty, speclflclty and posltlve pred~ctlve value (PPV) were calculated comparlng comblned hlgh r~sk and very hlgh rlsk women wlth perlnatal and maternal mortal~ty (for calculatlons see Appendlx 4, Tales 1 and 2) The senslt~vlty of thls tool was 65% for maternal mortallty and 53% for per~natal mortal~ty whlle the speclflclty was 68% and 69% respect~vely Because these outcomes are relatlvely rare, the PPV was extremely low (0 65~ for maternal mortallty and 6 8% for per~natal mortallty)

TABLE 11

Compar1son of Proport10n of Maternal and Per1natal Mortal1ty w1th Proport1on of Del1ver1es by Place of B1rth for Pre- and Post­

surveys Comb1ned (Probol1nggo and Pasuruan)

II of B1rth Maternal Per1natal I Place

Morta11ty Morta11ty B1rths I n \ n % n I

HOr"le 63 82 9 553 79 3 23716 85 Hosp_tal 1 1 14 5 129 18 5 3431 Health 2 2 6 15 2 2 535 Center/Pollndes

70tal (N) 76 100 0 697 100 0 27682

A r"Iaternal and per_natal death follow-up study was _npler"lented ~n Probollnggo at the same tlme as the rlsk scorlng sjster"l The PKK were _nstructed to report a maternal and/or per_~atal death to the sub-dlstrlct health center wlthln 48 hours Subsequently w_th.n one week, the mldwlfe or health

25

14 1

100

%

7 4 9

0

center phys~c.an performed a verbal autopsy aur.ng a hOMe _~_: to the fam~ly The completed quest.onna.re was forwaraea to t~e research team ~n Dr Soetomo Hosp~tal Surabaya W!th~n one Month a res~dent from the Department of Obstetr.cs and Gynecology v~s~ted the fam~ly for conf.rMat.on of the f.na.ngs from the orlg~nal verbal autopsy The res.dent obtalned further med~cal lnformatlon from the blrth attenaant, health center or hosp.tal when appllcable and ass.gned avo~dable factors

Of the 26 maternal deaths reported all famll~es were v.s.ted All deaths occurred .n the rural areas and none wa~ reported ~n the urban area 22/26 WOMen who del.vered at hone were attenaed by a TBA and one del.verl took place at a M.dw.fe's house Only two del.ver.es occurred .n the hosp.tal _n addlt.on one woman d.ed undel.verea .n the hosp~tal from placenta preVla The place of aeath for 20 women was the hone ~nc for 4 the hospltal Three women d.ea dur.ng referral or on arr.val to the hospltal

~lneteen of the 26 deaths were due to postpartum hemorrhage (77%) Of these women, 12 also had a retalned placenta and one an .nverSlon of the uterus Three women d.ed from eclampsla ana three from lnfectlon

A strlklng flnd~ng lS that all but three of the 26 deceased women were del~vered at home Of the three women attended In the hospltal two dled of lnfectlon The th.rd dled of suspected placenta prevla before blrth Slxteen of the 26 women were par.ty 1-4 and 14 between the ages of 20-34 conf.rm~ng that the maJorlty of deaths occur In the low r.sk' age/par.ty groups Seventeen women dld not comply wlth the recommended blrth attendant or place of del~very accord.ng to the rlsk score asslgned to them Nlne women were In the low rlsk group 12.n the hlgh rlsk and 5 In the very hlgh r.sk group When relat~ves were asked about the constralnts to acceptlng referral 14 stated

reluctance to be referred', 4 mentloned transport problems 4 clted cost 7 stated problems wlth the referral chaln Vla health center to hospltal, and 4 had no explanat.on The reasons for

reluctance to be referred' have not been el.clted further

Of the 363 reported perlnatal deaths (PND) 243 were followed up wlth a verbal autopsy Of the 243 deaths, 128 (52 7%) were stlllblrths 221/243 PNDs were del~vered at home (91%) and 193 by a TBA (87 7%) Analysls of the PND relatlve to asslgned rlsk factors In Group IlIon the rlsk score card shows that 72/243 (29 6%) occurred due to these compl~catlons Also there were three tlmes as many stlllblrths (SB) as early neonatal deaths (END) (54/18) The number of SBs to ENDs were as follows malpresentatlon 33/5, tWln pregnancy 6/6, lntra-uterlne fetal death 12/0, hydramnlos I/O, post-term 1/2, mother's medlcal d~sease 1/5

26

Causes of 115 ENDs asslgned through the verbal autopsy were asphyxla - 31 (26 7%), asplratlon - 11 (9 5%), convulslon - 12 (10 3%), fever - 14 (12 1%), low b~rth we~ght - 38 (32 7%), congenltal abnormallty - 6 (5 2%)

W~th the rnaJor~ty of these per~natal deaths del~vered at home by a TBA, It lS obvlous that labor and dellvery practlce skllls and lmmedlate neonatal resuscltatlon need to lmprove urgently If these deaths are to be reduced The maJor~ty of malpresentat~ons were due to breech presentatlon, whlch probably succumbed ~ntraparturn As long as there are not enough tra~ned profess~onal rn~dw~ves to prov~de sk~lled back-up to the TBAs, sensltlzat~on of farn~lles regard~ng danger s~gns and compllance wlth referral needs to be addressed The feaslblllty of lmprovlng the tra~nlng of TBAs In breech dellvery, resuscltatlon, recognltlon of prolonged labor and emergency treatment of postpartum hemorrhage sufflclently to reduce these deaths remalns a matter of debate and trlal Reductlon of the hlgh toll from perlnatal and maternal mortallty needs a well functlonlng matern_ty serVlce wlth effectlve llnkages between all levels and managerla1 and educatlonal supervlslon

6 5 Screened versus Unscreened Women

Durlng the post-lnterventlon perlod, women were asked If they had been screened by the PKKs A total of 72 1% of mothers responded that they had been screened whlle 27 9% stated that they had not been screened Soclo-demographlc and reproductlve r_sk factors were compared and there was no practlcal dlfference between screened and unscreened women In age, parlty, maternal eaucatlon thelr husband's educatlon and employment, and the c_str_but~on of rlsk factors In addltlon, no dlfference was found _n mode of dellvery (data not shown) Table 12 provldes a cOMpar_son of maternlty serVlce use rlsk groups, tetanus _MMun_zat_on status, and maternal and perlnatal mortallty between Mothers who were screened and those who were not

In general women who were not screened tended to utlllze antenatal serVlces less than women who were screened (63% vs 80% respect_vely) They were less l.kely to have recelved tetanus _MMun_zatlon after the 8th month of pregnancy (40% vs 23%), and consequently were more l...kely to fall lnto 'Hlgh" and "Very Hlgh r_sk groups compared to the screened women (53% vs 41%, respect_vely)

Wh_le there was no slgnlflcant dlfference In place of eel_very and blrth attendant between screened and unscreened women the latter group had a hlgher percentage of dellverles In fac_l_tles by doctor/mldwlfe by the low rlsk women (Table 13) Wh_le there was no marked dlfference In perlnatal mortallty between unscreened and screened women (45/1 000 vs 4011,000) maternal mortallty was almost double among the unscreened women (573/100 000 vs 2981100 000) but the numbers are small (11 versus 15 deaths)

27

TABLE 12

Compar1son of Selected Character1st1cs between Screened and Unscreened Woman for the Post-survey, Probol1nqqo, 1992-1993

Character1st1cs

n

Antenatal Care 4099 Posyandu 937 Pol~ndes 206 Health Center 2635 Hosp~tal 321 1\10 Care (PKK or TBA) 1028

No Tetanus 1215

R1Sk Group Low 3051 Hlgh 1860 Very Hlgh 216

Place of Del1very Home 4409 Pollndes 8 Health Center 83 Hospltal 629

Total B1rths 5152 Llve Blrths 5034 Stlll Blrths 118 END 88 Maternal Deaths 15

MMR/100,000 LB" 298 PMR/I000 LB 40

Early Neonatal Death Maternal Mortall.ty Rat10 Perl.natal Mortall.ty Rate

Post-survey

Screened N=5127

\

-9 9 22 9

5 0 64 3

7 8 20 1

23 6

59 5 36 3

4 2

85 9 0 2 1 6

12 3

0 0

28

Proboll.nggo I Unscreened I

I N=1980 \ n \

1220 62 6 150 12 3

24 2 0 892 73 1 154 12 6 760 38 4

800 40 4

924 46 7 943 47 6 113 5 7

1518 81 3 4 0 2

30 1 5 337 17 0

1983 1919

64 26 11

573 2 45 4

TABLE 13

Comparison of Delivery Place and Blrth Attendant between Screened and Unscreened Women by RiSk Group for the Post-survey, Probol1nggo, 1992 - 1993

Post-survpy -- Scrppned (N=5172) Po~t-SUlvPy -- Un~creened (N=1980)

Placp/ Low RlBk H1gh Rl..,k Vpry Hlgh RlSk [ow RISk Hlgh RlSk Very HIgh RISk Attendant N"']051 N 1860 N=216 Il=924 N=943 N=113

n \ n % n % n % n % n %

Hol'IP 21)6'; 84 I 16 ]J 8<1 4 1814 8] 8 61l) 73 9 83] 88 3 93 82 3

TBA 201 7 8 I 0 1481 89 I 164 90 6 525 76 9 759 9 I 1 85 91 4 Mldw If e 488 Iq 0 182 10 9 17 9 4 158 23 1 74 8 9 8 8 6 Doctor - - - - - -

Health Cpntpt I) 7 I 8 ]0 I 6 4 I 9 2 J 2 5 9 1 0 2 1 8

Mldwife 57 100 0 ]0 100 0 4 100 0 23 100 0 9 100 0 2 100 0 Doctor - - - - - -

Hospltal 429 14 1 167 9 0 31 14 3 218 23 6 101 107 18 15 9

Mldwlfe 304 70 9 99 59 3 18 58 1 168 77 1 63 62 4 7 38 9 Doctor 125 29 1 68 40 7 13 41 9 50 22 9 38 37 6 11 61 1

29

TABLE 14

Soc1o-demograph1c Factors, Antenatal Care and R1Sk Groups by Rural and Urban Areas for Post-survey 1n Probol1nggo, 1992-1993

Post-survey Probol1nggo

Var1ables Rural Urban N=5994 N=111J

n " n \

Age yrs

<'16 132 .., 2 3 J ..I .. 1~-19 1133 1 d 9 69 ') ~

20-34 4294 ~ 1 6 944 d4 0

~35 435 ~

3 9""' 15 -

Age of youngest ch1ld

<' 2 years 152 2 5 38 3 ~ -Par1ty

0 2724 45 5 385 34 b

1 1717 28 6 334 30 0 2 829 13 8 199 1 ~ d 3 375 6 3 96 8 b

4 164 2 7 40 3 b

~5 183 3 1 49 4 4

Educat10n of Woman (Years)

0 754 12 6 51 4 6 <4 1543 25 7 126 11 3 4-6 2784 46 5 360 32 3 7-9 459 7 ""' 209 18 8 I

10-12 393 b 6 313 28 1 >12 61 1 0 54 4 9

Occupat1on of Husband

LaDor 2640 44 0 543 48 8 Farmer 2063 34 4 27 2 4 Fisher 65 1 1 29 2 6 Mercl)ant 474 7 9 86 7 "7

Gov Empl 620 10 3 411 36 9 Unspec 132 2 2 17 1 5

Antenatal Care

Heal.th 977 87 8 Facllltles 4342 72 4 35 3 1

Posyandu 1052 17 6 17 1 5 Polindes 213 3 6 679 6 1 Health Center 2848 47 5 246 22 1 Hospltal 229 3 8 136 12 2 None 1652 27 6

No Tetanus 1919 32 0 96 8 6

Screened 4473 74 6 654 58 8

30

I

I

I

I

I

I

I I

I

I

I

I I

6 6 Urban and Rural Women

Respondents from Probol~nggo were categor~zed ~nto rural and urban areas dur~ng the pre-survey, post-survey, and dur~ng the lmplementat~on per~od Because of the slm~lar~ty of results and the hlghly slgn~f~cant d~fferences between rural and urban populatlons In the pre-survey, the post-survey and the lmplementatlon categorles, only the post-survey urban rural d~fferentlals are presented (Table 14)

The age dlstrlbutlon shows a slgn~f~cantly hlgher proportlon of teenage pregnancles (~ 19 Years) ~n the rural compared to urban area (21% vs 7%) A greater proport~on of women In rural area had less educatlon than women ~n the urban areas, partlcularly for women wlth less than four years of educatlon (38% vs 16%) In the rural areas 79% of husbands were employed as laborers farmers and flshermen as compared to 54 % of husband In the urban areas

Only 72% of women In the rural areas recelved antenatal care as compared to 88% of women In urban areas A very strlklng result was the fact that 32% of rural women had not recelved tetanus lmmunlzatlon by the 8th month as 'compared to 9% of urban women It lS noteworthy that 75% of rural women were screened by the PKK compared to 59% of urban women

D_fferences were also noted In rlsk status w~th more women _n the rural areas In the hlgh rlsk categor~es, 47% versus 27% Th_s a_fference lS most llkely due to d~fferentlal tetanus _mmun_zatlon status

Place of dellvery and dellvery attendant were slgnlflcantly c_fferent for urban and rural women among all rlsk categor~es (Table 15) For all rlsk groups urban women were much more l_kely to dellver In the hospltal In fact, 50% of urban low rlsk ael_verea _n the hospltal In contrast rural women were much nore l_kely to del~ver at home wlth about 90% In all rlsk groups TBAs attended 81% rural women versus 26% urban women The mldwlfe playec a much greater role .n attendlng blrth In urban areas (65% versus 16%)

Per_natal mortal_ty was evaluated In rural and urban areas by r_sk group and screen.ng status (Table 16) Perlnatal nortal_ty was slgnlflcantly h.gher among the unscreened women In the rural areas (p=O 05) 7he marked dlfferneces were ~n the low and h.gh rlsk groups The Opposlte was true for the urban area but nuMbers are very small .n the unscreened women

31

TABLE 15

Place of Del~very and B~rth Attendant by R1Sk Group 1n Rural and Urban Areas for Post-survey 1n Probo11nggo, 1992 - 1993

------ - - ---

Rural (N=5994) Utban (tl=1113)

Place/ Low R1Sk Hlgh R1Sk Very Hlgh Ru,k Low Ru,k High Ri~k Vu y Illgh Rlbk Attendant N=3163 N=2534 N=297 N=8lL N=269 tJ=3l

n % n % n % n % n % 1\ %

Home 2857 90 3 2349 92 7 265 89 2 391 48 2 1~7 54 7 9 .28 1

TBA 2405 84 2 2155 91 7 244 92 1 197 50 ~ 85 57 8 5 55 6 MldWlfe 452 15 8 194 8 3 21 7 9 194 49 6 62 -12 2 ~ 44 4 Doctor 0 0 0 0 0 0

Health Center 69 2 2 37 1 5 6 2 0 1 1 1 4 t- O 7 0

Mldwlfe 69 100 0 37 100 0 6 100 0 11 100 0 2 100 0 U Doctor 0 0 0 0 0 0

Hospltal 237 7 5 148 5 8 26 8 8 410 50 4 120 H b L3 I 1 CJ

Mldwlfe 125 52 7 70 47 3 10 38 5 347 8~ b 91. lb 7 15 b'l 1. Doctor 112 47 3 78 52 7 16 61 5 63 15 4 28 d ) I) H 8

32

TABLE 16

Compar~son of Per~natal Mortal~ty by R~sk Group and Screen~ng Status ~n Rural and Urban Probol~nggo (Post-survey) 1992 - 1993

Rural Urban

SCREENED

Low R~sk 2656 33 33 25 7 486 1 6 14 4

H~gh R~sh. 1728 60 38 56 7 152 3 0 19 7

Very H~gh R~sk 200 20 9 145 0 21 1 2 142 9

TOTAL 4493 I .13 I 80 I 42 9 659 I 5 I 8 I 19 7

UNSCREENED

Low R~sk 598 13 8 35 1 326 1 0 3 1

H~gh R~sk 824 39 14 64 3 121 0 0 -Very Ihgh R~sk 102 .... 4 147 1 12 0 0 -TOTAL 1524 I 63 I 26 I 58 4 459 I 1 I 0 I 2 1

7 DISCUSSION

There ~s an ~ncreas~ng debate ~n ~nternat10nal fora about the effect~veness of antenatal care (4) A maJor accompl1shment of th~s proJect was the ~mplementat~on of the antenatal r1sk scor~ng card by l~terate women volunteers (PKK), all non-health profess~onals ~n 12 sub-d~str~cts compr1sed of 162 v1llages These PKK have shown enormous comm1tment and have sacr1f1ced much of the~r t~me otherw~se devoted to the1r fam1l1es, to teach women about pregnancy In part~cular they have encouraged them and ~he_r fam~l~es to seek care from m~dw1ves and phys1c1ans and to conply wlth referral dur~ng pregnancy Th1S proJect has aemonstrated team work ana delegat10n of respons1b1l1ty from the h_ghest to the lowest level of health serV1ces, w1th comm1tment to support_ve superv~s~on fron all sectors respons~ble for .nplementat1on of th~s strategy

Wh.le the preclse proport.on of women contacted by the PKK .s unknown they d~d contact at least 72% Th~s was demonstrated bJ the compar~son of the ~nplementat~on data and the post-survey results The analys~s lS l~n_ted by the fact that the women 1n the post-survey and the .nplementat~on were not l~nked If the b.rth rate of 22/1000 for East Java can be appl1ed to Probol.nggo approx~mately 11 984 b~rths should have occurred over a 12 months per~od Only 8375 women who gave b1rth were .aent~f~ea ~nd~cat~ng a 30% shortfall The almost equal number of women 1dent1f~ed ~n the post-survey and the 1mplementat1on over the same n~ne-month per10d (7101 versus 7049) suggests a lower b~rth rate for Probol~nggo rather than a 30% underreport.ng

33

In order to measure the effect of the r.sk score cara _mplementat~on, the study deslgn encompassed retrospect_ve pre­and post-surveys both ~n the lmplementatlon and compar_son areas and prospect~ve data collect~on ~n the .mplementat~on area Ideally ~ntervent~on and comparlson cornrnunlt~es should have slmllar SOClo-economlC status demographlc factors and health serVlce dlstrlbut~on In thlS stuay even though there were no ~_gn_f~cant dlfferences between pre- ana post-survey f_na_~gs _t appears that Pasuruan had lower eaucat_onal levels for both pregnant women and husbanas and a larger percentage of ~o~en w_th parlty > 5 About 70% of men were far~ers and laborers _n both areas

ThlS study evaluated the use of an antenatal screen_ng tool as a means of ldentlfYlng women at _ncreased rlsk of an aaverse obstetrlcal outcome Data were not ava.lable on compl_cat_ons of labor and del~very and thus outcomes evaluated conslstea solely of maternal and per_natal mortal_ty

Data were collected d~fferently dur_ng the lmplementat_on perlod For example aurlng the lmplementatlon perlod data on occupat~on and educatlonal level were obtalned through open-ended auestlonnalres whlle durlng the survey categorlcal data were obtalned Consequently the prospectlve analysls ~n Probol.nggo shows a slgnlf~cant d~fference from the post-survey ~n the same area Educat~onal levels are recorded as hlgher dur~ng the prospectlve study and there lS a change from laborer/farmer to unspeclfled employment of 30% Reportlng blas both by responaents and lntervlewers must have played a role In both changes Also the dlfferences are lmpl~c~t In retrospectlve versus prospect~ve data collectlon

The composltlon of the rlsk scores was derlved from demograph~c and reproductlve rlsk markers, emergency obstetrlc compllcatlons of eclampsla and antepartum hemorrhage and suspected med~cal and obstetr~c compl~cat~ons The compllcat~ons were conf~rrned by a rn~dw~fe or doctor after wh~ch the curnulat~ve rlsk score was changed Obv~ously obstetr~c cornpl~cat~ons were e_ther underreported or underrecorded The PKK held the card as a health educat~on tool and to serve as a rern~nder of the next V1Slt Slnce the pregnant women d~d not have possess~on of the score cards, these could not be changed If compllcatlons were dlagnosed durlng antenatal check-up at the posyandu, health center or hospltal The score therefore was only changed lf the woman conveyed any compllcatlon to the PKK who then changed the score ln consultatlon wlth the rnldwlfe For 92% of women the rlsk score never changed, although 75% were seen ~n the last month of pregnancy ThlS means that the rnaJorlty of hlgh r~sk scores were determlned by dernographlc and reproductlve rlsk factors and the lack of tetanus lmmun~zatlon (TT) after the 8th month of pregnancy

34

The lack of TT lmmunlzatlon lnfluenced the scores greatly as It added four pOlnts to the score, thus shlftlng a conslderable proportlon of women from lower to hlgher scores Fortunately for mother and baby, tetanus can be prevented through a prlmary health care lnltlatlve and should not requlre the woman to be referred for obstetrlcal care at a hlgher level faclllty at great expense Hence, thls shlft to hlgher scores caused by addlng In

no TT lmmunlzatlon does not truly reflect obstetrlc rlsk status that does requlre hospltal management But once added In, scores are not decreased, even If the woman then has TT lmmunlzatlon

Whlle there was a marglnally hlgher proportlon of women among hlgh and very hlgh rlsk groups who sought hospltal aellvery compllance fell far short of the 60% target for very hlgh r_sk women to dellver In hospltal Women wlth a score malnly maoe up of reproductlve rlsk factors and lack of tetanus _MmUn_zatlon wlII not comply wlth advlce for referral when they are feel_ng well Flnanclal barrlers are a deterrent to hospltal del.very but so lS the low avallablilty of health facllltles and M_ow~ves In the commun~ty

Women were counselled by the PKK on the approprlate place of oel.very consonant wlth the cumulatlve rlsk score durlng the last antenatal contact Results provlde eVldence that there was no _ncrease _n the proportlon of hlgh rlsk women dellverlng In health facllltles when pre- and post-surveys are compared Reasons for the lack of des~red program effect can be found both _n the compos~tlon of rlsk factors constltutlng hlgh rlsk scores ana the reluctance of women to move out of a tradltlonally cOMfort_ng and non-threatenlng enVlronment durlng labor Furthermore dellvery costs are prohlbltlve for the ma]Orlty of people partlcularly In rural areas Furthermore, for the 30% of ~onen oes.gnated as hlgh rlsk who could dellver at home or In a heal~h center wlth a m.dw_fe sufflclent staff and facliltles ~ere not avallable W_th the present number of mldwlves, thlS ~oulc have meant an average of 116 blrths/mldwlfe per annum whlch _s not feas~ble conslder.ng the great dlstances and mountalnous ~erra_r to be coverec

Unl_ke the pllot study conducted In Sldoar]o dlstrlct, In th_s study. rlsk scor.ng d_c not appear to reduce perlnatal nortal.ty On the contrary both reported maternal (MMR) and per_natal (PMR) lncreased _n the post-survey In both the _nplementatlon and compar.son areas Instead of attrlbutlng thls phenoMenon to deterlorat_ng health and serVlces, thls lS slmllar to exper_ences In other countr.es that both the MMR and PMR rlse _n_t_ally when data are recoraed more accurately

R_sk factors ldent_f_ed durlng the lmplementatlon perlod cons_steo pr.mar.ly of reproouctlve factors, such as age, parlty anc obstetrlc hlstory Cards were to be revlsed as compllcatlons were _oentlf_ed but _n practlce thlS seldom occurred Thus, the

35

r_sk group~ngs were compr~sed predom~nantly of r~sk factors aeterm~ned dur~ng the f~rst antenatal v~s~t D~agnos~s of compllcatlons durlng pregnancy was very low 1n thls stuay compared to World Health Organlzatlon estlmates that 30% of women need some medlcal attentlon for compl_catlons In pregnancy and that 15% develop llfe threatenlng compl_catlons dur1ng ch_ldblrth Data on compl1catlons dur_ng labor and del_very were not recoraed ~n the 1mplementat1on area Although women were asked about such compl1cat1ons dur_ng the pre- and post-surveys the structure of the quest1onna1re produced 1nsufflc1ent responses that d~d not permlt deta_lea analys.s

An _ncreased MMR and PMR were noted for women 1n the h_gher r_sk categor1es Even 1n the very h~gh r_sk category however few women experlenced e1ther maternal or perlnatal mortal_ty As ~ result the use of th~s tool produced a h~gh number of women _centlfled as h1gh rlsk who dld not experlence an adverse outcome Furthermore due to the low 1nc_dence of these outcoMes the PPV was extremely low Even a tool wlth hlgher senslt.v_ty dnd spec1f1c.ty would have produced these results as lt _s a_ff_cult to pred~ct rare outcomes uS1ng a screen~ng tool

Alexander and Ke1rse (5) have rev1ewed the data of varlOUS scor1ng systems used to screen for 1ncreased r1sk of per1natal mortal1ty, preterm labor low b~rthwe~ght and low Apgar score at b1rth Overall, the sens1tlv1ty of the scor1ng system was strongly related to the type of outcome pred1cted For perlnatal Mortal1ty Wh1Ch has a low prevalence sens~t~v1ty ranged from 65 to 90% 1n the 15 stud1es the authors rev1ewed (6-20) Spec1f1c1ty was nearly always h1gher than sens1t1v1ty rang1ng from 38 to 97% Pos1tlve pred1ct1ve value was generally very poor w1th the except10n of one study from Ind~a where the PPV was 40% (14) In these stud~es, between 10% and 30% of women who scored as h1gh r_sk exper1enced an adverse outcome Wh1Ch corresponded to r_sk allocated to them by the scor1ng system

One of the WHO and UNICEF 1nd1cators for mon1tor1ng maternal mortal1ty lS the cesarean sect10n (CIS) rate a range of 5%-15% of expected b1rths lS consldered as the acceptable level (21) ApplYlng a 5% cIs rate 1n th1S study, a total of 422 cesarean sect10ns would have been expected 1n the 1mplementatlon area Only 64 were performed, representlng 0 8% of all b1rths No rural to urban dlfferent1al was found It lS 1nterestlng to note that the proport1on of cesarean sect10ns 1S d1fferent when compar1ng low and very h~gh r1sk groups, e g , 0 3% vs 15 9% 1n rural areas and 0 6% vs 7 1% 1n the urban areas Caut10n ~s necessary ~n applY1ng the cIS 1nd~cator and ~nterpret1ng the seem~ngly low cesarean sect~on rate Commun1ty data for the def1n1tlon of an 'ldeal cesarean sectlon rate' to reduce maternal and per1natal mortal~ty are not ava1lable for East Java, and the notlon that 1ncreased cesarean sect10n rates w1ll produce better per1natal outcome lS st1ll controvers1al (22)

36

Maternal deaths were ~dent~f~ed dur~ng the r~sk score ~mplementat~on and reported by the PKK to the health center The total number of deaths ~dent~f~ed through th~s system dur~ng the f~rst n~ne months was 18 In add~t~on e~ght deaths occurred dur~ng the rema~n~ng three months of the year In the post­survey, 26 deaths were ~dent~f~ed retrospect~vely over n~ne months -- 15 among the screened women and 11 among the unscreened It ~s poss~ble that not all those who responded to the quest~onna~re for the deceased women knew ~f they were screened by the PKK Thus there could have been 18 deaths among the unscreened ~nstead of 15 It ~s cur~ous that apparently more aeaths were reported In the post-survey compared to the careful aeath follow-up ~n the ~mplementat~on per~od of the r~sk score cara unaerl~n~ng the po.nt that underreport~ng of maternal aeaths ~s un~versal

8 CONCLUSION

In sp~te of the great comm~tment of all PKK and f~eld staff to us_ng th.s r~sk scor~ng system ~n the commun~ty, there was no program effect Among reasons for lack of compl~ance w~th recommemnded place of del.very and b~rth attendant was the short _~plementat~on per~od (one year) and the fact that the system was not strengthened to acco~odate a substant~al ~ncrease ~n referral e_ther to a m.aw~fe 1n the home or to a health fac~l~ty

Wh_le the antenatal r~sk score card can funct~on as a ~arn.ng and educat.on tool to recogn~ze compl~catlons, r~sk scor_ng based ma~nly on demograph~c and reproductlve factors w~ll ~ot conv.nce women to use a system when they do not bel~eve ~n the r.sk markers wh~ch allocate them to the h~gh r~sk groups A :drge proport_on of women laent~f~ed as h~gh r~sk go on to have uneventful del.ver1es wh.le ~any of the low r~sk women do develop l_fe threaten.ng compl.cat~ons requlrlng emergency treatment

The sens.t.v.ty spec.f.c.ty and PPV for maternal and per_natal mortallty are not good enough to recommend general~zed doopt.on of th.s rlsk scor.ng system Several steps are recoMMended for the future F.rst lack of tetanus ~mmunlzatlon neeas to be taken out of the r.sk score ~n order to avo~d dilocat.ng women to an art.f.c.ally hlgher obstetr~c r~sk score for wh.ch del~very 1n a health facllltY1S recommened Second ~onen should be encouraged to carry the card when they attend fornal antenatal care If co~pl~cat~ons are d~agnosed, they can be recoraed on the card alert.ng the woman and her fam~ly that she has a h.gh r1sk pregnancy and that more severe compl~catlons can oevelop Th.s may obv.ate a scor~ng system per se as the aliocat.on to a r.sk group durlng pregnancy may ~nduce anxlety anc unouly alarm the woman and her fam~ly Flnally, compllcat1ons

37

durlng labor dellvery and the postnatal perlod should be _ncluded on the card

No screenlng system can subst_tute for cornrnun~ty

eaucatlon on danger slgns and compl_catlons as these can aevelop at any t~me The cornrnunlty can be lnvolved to set up a transport system for emergencles and a health serVlce neea to be aes~gned to provlde hlgh quallty care and a capablilty to treat obstetr~c emergencles Geographlc cultural and economlC barr_ers w_ll remaln a reallty In the search to _mprove access Solut_ons to these sltuatlons and sustalnab.l.ty wlll requlre cont_nuous bu~ldlng of partnershlps between the government, non-governnental ~ectors and cornrnunltles

38

REFERENCES

1 Indones1a Demograph1c and Health Survey (IDHS) (1993)

Bureau of Stat1st1cs, M1n1stry of Health, Jakarta,

Indones1a

2 Government of Indones1a and UNICEF (1994) Sltuat10n

Analys1s of Women and Ch1ldren 1n Indones1a

1994 UNICEF Jakarta Indones1a

Draft, January

3 Roch]at1 PH (1990) Implementat10n of a r1sk scor1ng system

for pregnant women by the PKK 1n D1str1ct Sldoarfo PhD

thesls Dr Soetomo Hosp1tal/Med1cal College of Alrlausso

Unlvers1ty Surabaya

4 Rooney C (1992) Antenatal care and maternal health How

effect1ve lS 1t? World Health Organ1zat1on (Document

WHO!MSM!92 4) WHO Geneva SW1tzerland

5 Alexander S, Kelrse MJNC (1989) Formal r1sk scor1ng durlng

pregnancy In Effectlve care ln pregnancy and Ch1ldb1rth

vol 1 Pregnancy pp 348-365 Eds Chlamers I Erk1n M

Ke_rse MJNC Oxford Un_verslty Press, Oxford

6 Akthar J Seghal N (1980) Prognostlc value of a prepartum

ana _ntrapartum r_sk-scor_ng method South Med J 73 411-

414

Casson RI, Sennett ES (1984) Prenatal r1sk assessment and

obstetrlc care ln a small rural hosp1tal Comparlson wlth

gu_dellnes Can Med Assoc J 130 1311-1315

8 Edwards E Barrada I Tatreau RW, Hakanson EY (1979) A

s_mpl_fled antepartum rlsk-scorlng system Obstet Gynecol

54 237-240

9 Goodw~n JW Dunn JT Thomas BW (1969) AntepartuM

~dent~f_cat_on of the fetus at r_sk Can ~ea Assoc J .0.

458-464

10 Haer~ AD South J ~alarett J (.Q-4) A scor_ng systen :or

~aent~fYlng pregnant pat_ents ~_th a hlgh r_sk of per_ndt~~

nortallty J Obstet Gynaecol Br COmMwlth 81 535-538

11 Hallday HL Jones PK Jones SL (1980) ~ethod of screen_~~

obstetrlc pat1ents to prevent reproauct_ve wastage Ob~te~

Gynecol, 55 656-661

12 Hobel CJ Hyvar1nen ~~ Okaaa D~ Oh ~ (1973) Prenatal ana

~ntrapartum h1gh r_sk screen_ng I Pred1catlon of the h_gh

rlsk neonate Am J Obstet Gynecol 117 1-9

13 McCarthy BJ Schulz KF Terry JS (1982) IdentlfY1ng

neonatal r1sk factors and prec_ct_ng neonatal deaths ~n

Georg1a Am J Obstet Gynecol 142 557-562

14 ~ohapatra SS (1982) Slmpl_f_ea scor_ng system for

ldent1flcatlon of hlgh r1sk blrths Evaluatlon 1n a rural

communlty Indlan Pedlatr, 19 913-915

15 Morrlson I, Olsen J (1979) Perlnatal mortallty and

antepartum rlsk scorlng Obster Gynecol, 53 362-366

16 Nesbltt R, Aubry R (1969) Hlgh r_sk obstetrlcs II Value

of semlobJectlve gradlng system _n _dentlfYlng the

vulnerable group Am J Obstet Gynecol 103 972-985

17 Rantakalllo P (1969) Groups at rlsk 1n low blrth welght

lnfants and perlnatal mortallty Acta Paedlatr Scand (Suppl)

193 5-71

18 Rumeau-Roquette C, Breart G, Denlel M, Hennequln JF, du

Mazaubrun C (1976) La notlon de rlsque en perlnatologle

Resultats d'enquetes epldernlologlques Rev Epldernlol Sante

Publlque, 24 253-276

19 Sokol RJ Rosen MG StoJkov J, Chlk L (1977) Cllnlcal

appllcatlon of hlgh-r~sk scorlng on an obstetrlc serVlce Am

J Obstet Gynecol 128 652-656

20 W_lson EW, Slll HK (1973) Identlflcatlon of the hlgh rlsk

pregnancy by a scorlng system NZ Med J, 78 437-440

21 ~a_ne D et al (1992) GUldellnes for monltorlng progress In

reauctlon of maternal mortallty A work In progress Unlted

~at~ons Chlldren 5 Fund Statlstlcs and Monltorlng Sectlon

October 1992 3 Unlted Natlons Plaza, New York, NY 10017

22 De Muylder X (1993) Caesarean sectlons In developlng

countrles some conslderatlons Health Pollcy and Plannlng,

8 (2) 101-112

APPENDIX 1

APPENDIX 2

APPENDICES

Antenatal R~sk Score Card

Safe Motherhood Quest~onna~re for Pre-surveys and Post-surveys Probol~nggo and Pasuruan

R~sk Factor Analys1s by Total Score and R1Sk Group for Probol~nggo Implementat~on (D~str~ct = rural, and Mun~c1pal~ty)

Table 1 Dlstrlbutlon of RlSk Factors wlth Total Score/Rlsk Group by the RlSk Scorlng System Probollnggo Dlstrlct (Rural)

Table 2 D_strlbutlon of Double RlSk Factors wlth TT Total Score/Rlsk Group by the RlSk Scorlng System Probollnggo Dlstrlct (Rural)

Table 3 D_str.butlon of Double RlSk Factors, Total Score/Rlsk Group by the RlSk Scorlng System Probol_nggo Dlstrlct (Rural)

Table 4 D_str_butlon of Three RlSk Factors wlth TT Total Score/Rlsk Group by the RlSk Scorlng System Probol.nggo Dlstrlct (Rural)

Table 5 Dlstrlbutlon of Three R1Sk Factors Total Score/R_sk Group by the R1Sk Scorlng System Probol_nggo Dlstrlct (Rural)

Table 6 Dlstr_butlon of Four R1Sk Factors wlth TT Total Score/R.sk Group by the R1Sk Scorlng System Probol_nggo D.strlct (Rural)

Table - D_str_but~on of Four R1Sk Factors wlth TT Total Score!R~sk Group by the R1Sk Scorlng System Probol_nggo Dlstrlct (Rural)

Table 8 D_str.but~on of R1Sk Factors, Total Score/R.sk Group by the R1Sk Scorlng System Probol_nggo ~un~clpallty

Table 9 D.str~butlon of Two R1Sk Factors Total Score/R_sk Group by the R1Sk Scorlng System Probol~nggo ~un.clpallty

Table 10 D.str.butlon of Three RlSk Factors, Total Score/R~sk Group by the R1Sk Scorlng System Probol_nggo ~unlclpallty

APPENDIX 3

APPENDIX 4

Table 11 D~str~but~on of Four R~sk Factors Total Score/R_sk Group by the R~sk Scor~ng SysteM Probol~nggo ~un~c~pal_ty

Table 1 Maternal and Per1natal Morta11ty by R1Sk Groups for Probo11nggo and Pasuruan

Table 2 OverV1ew of Total Women, B1rths, Maternal and Per1natal Death for all Study Per10ds and Sub­d1v1ded by Urban/Rural for Probo11nggo

Table 1 Per1natal Morta11ty by Antenatal R1Sk Score, Probo11nggo, Implementat10n Sens1t1v1ty, Spec1f1c1ty and P051t1ve Pred1ct1ve Value

Table 2 Maternal Mortal1ty by Antenatal R1Sk Score, Probo11nggo, Implementat1on. Sens1t1v1ty, Spec1f1c1ty and Pos1t1ve Pred1ct1ve Value

APPENDIX 1

Antenatal Risk Score Card

Sdle Motherhood Questionrunre for Pre-surveys and Post-surveys Probolinggo and Pasuruan

~ ...... -......... -I I I •

De v'" r v 141 ~ t:xt. liiln:

~~ #IIho Ib>d\

D

I! .::: I:: 111\ IQII ~ ~ fa -d>. f\.l I.e ILC I.,... ..II!UI -I

I.

,-I-- ---I- - - 1--I - - -- - - - f.- -- - - 1- - - - - --I

- - - - - - - - i---• I - ,- -I - - -- --" - - --, -- .. _ ........

Delivery date •••

Place :

.. ...... . . Birth Attendant I

10TBA 1 0 ttlthers hare

2 0 Midwife hare

1 0 Heolth Centre

.. .0 Hoepltal

2.0 Midwife

3 0 DJctor

Mode of dellveq I 1 OSPlIltaneou&

Mother

Baby

2. D Voglnal op dellvuy

3 D Coe84reM Section

I 1.Oillve 2 0 deoth, C3UBe8 •• • •

I 1. o Hale 2 0 Fanale

3 Dwve 4.0Stlllblrth

5 Otk:nltzll. dmth, 9 • d¥ Cll.Be8 ••• •••••••••

Baby birth wei~t I •••••••• gran

C'algenitol onanaly I 1.0 non

2 Dyes,

y. ~

00 ~~

PRlN HCIfUEAl TH SERV ICE EASIJAVA PROVINCE

p([{)JI fm{)A TI sr:mE CARD BY CAJ:re;

~nt wcmen I HrII

&lucatioo

OcupIstion I.

10ddresa

ViJ..loge

Subdistrict I

Oistriet~icipal

•• fbbond •

..

Mother' 8 foed As long as you are pre!:1lOnt do YB,take iron tablet e 1 no 2 yes, total tablet

9 YeO byel DmA 3.DHldw 2 Ocaire .( 0 1I C

Baby'. food e Breast feeding I

1 0 yea 2 n no, El.Qllmmt

lACTATIt{; HJTf£R IS A lOVElY HJH£R

~tllY Planning I 1 don't know yet • yea, 1 0 CDndaII ~ 0 pill 3 O~ .( 8 IqiliInt Ii 0 1m

6 ttUe .un 1 .... 1m 1 .. ORmUe ato::ils

cadm I Mea Ocupotioo

Jleolth Centra

Age I

~t1.on

Village StbJ • • Oist ""Juie

years

ANTEP AaTU'! SeaRl fiG FORM G P

Last ~enstru&tion Date Pre~anc:y ace aonths

Part A Obstetrlc HlstOry Education Referral tor prefnancr tD Health Center and ""_1nQ' ~ dell.~

!'Iuaber Condition of .other iCriteria A,e ,roup to scor. I---,.---r--"" Score

-1 9 ~O-34 35+

~LCi~lr;an;2d;.;.;:U==1 't1;lp~ar~a~ ___ .fIP:.:;ar::.:~i:.:·t~'...;I:.;V;...:o~r_ao::::.:r:';.=--_____ "i~3!: 6 ~ ~ 2 ~er_~" -.ears old ~~ • 3 Yoan!est child ( 2 y.ars ....

'foun~est 10 Tears or IICIrt ....

" Low be1,ht. .i 145 ca I-Parl tr 0 .. I-ParUr I or .ore with DO

tera s1!2ntaneous life born S Poor Obstetrlc liistory I-Pari ty 1 vi tb pre, vutace

abortion, pre.sture, f.tal death or neonatal death

I-Paritr II or 80re precnancrloOUtage 12 tiaes

I-Fetal death in last preJ1W1C1' CI IHlStorr CllU1CUlt Curtb P'O .ect~oa

I ; Priol" Section

~ forc:eps or T&C1lWI extractioa I-a.&DW ".oval ot placeata ilnLu.ion/transtll.ion~

,

4 ITotal seore

Put 8 CondlUoa of Pre~&DC'Y - aef.rral need

I Period of ,estatlon 1D IICInth-

Educ:&tiOD IIOtiTstiOD contact - score \uaber Condition of .other and referral Score ~"""-""'-""-~-"'--"'r---;

8 B1Htl1n, ~r(eDC1' 8 Ineed help &Dd

3 S 1 8 9 9 9+

t-__ -+~--~---~Ir.f~t,erral to Ho.pi tal 9 £.c:laapal&( coaTUla loa r-i8-t~~3~:;:!::~~~:3---t--r--t---i

10 TT iuuzu .. tion !Soon injection .. (no laauDiaatlon Tet on 8 IIDDtJl)

11 SuaPfctrd uai factol A ~edlc&l di..... ..t.rred to Health Ceater ....

AD.aia, Malariu, Pubow Tubcn:v-10.1a, DecoapaD -.atio Cordis D'(

Part 8 tauL score Part A tata.! score Part lj;1>AI total .core

iderr&l for' prepaaCT (flC or ho.~ital)

Delivery Site Atternant

Low Risk 'I'BA 6-10 • f'UdwUe Health Cent:re (HCl House Pcndok BersAl.l.n HC Hl.dwl.te

12· very H R • Dxtor

-- -- l-f&

1

SAFE l\10THERHOOD QUESTIONNAIRE

Delivered ~iothers: Aug 1992 - Apn11993 foto Respondent· I I I I I I I 1

?-tame of interviewer·

Date or Interview I I I I I i I 2

A RESPONDENT lDENWy

I Name

2 Addreu

Vllllge

Subciulnct (a)

Health Centre (b)

3 Category of Re5pondenl 0 J Delivery mother 2 Husband J 3 G rand mother 4 Grand molher mlaw 5 Suter 6 Other relillves IT] 4

4 Age (yean) 5 Education

I None 2 Elementarynon I:radualcd 0 5 3 Flementary 4 Juruor hlah school 5 Semor high achool 6 AcademyfUnlVenlty IT] 6 The length of C(jucatlon In vean 6

7 MllnJob In the 1asl one yell 1 None 2 LAbour 0 1 3 Firmer 4 F"hennan 5 Merchant 6 Employe Gov officer! Army

0 8 Any s.1lary 1 No 8 2 Yea

9 Income monthly Rp 9 10 Religion

I 1,llm 2 (hnshan

3 Chalohe 4 Hindu D 10 5 Budhl 6 Ochen

B IDENTITY OF HUSBAND

("lot lobe filled ... hen the b\1Sband hllnscH I.S re..(pont.ient) II Name

B • 12 A" (yan) 12 13 Educahon 11

I None 2 Elementary non brldUile ) [Iementary school 4 Junior high s.chool

- 5 Senior hlEh Khool 6 Acauemy/Umvenlty IT] 14 The length or WUCllion to yean 14

IS Mil n Job In the lut one year 1 None 2 LAbour 0 IS 3 Farmer 4 Fishennan

~ S Merchant 6 Employe Gov orrlcer! Army , 16 Any ulary I No D 16

i 2 )es • 17 Income monlhly Rp 17 .. -- - - -

2

C. SOCIAL ECONOMIC

t~·. 1-_____ �_s __ c_o_nd_I_II_0_n_O_f_~ __ h_o_~ __ (_ro __ m_~_~ __ ~ __ II_h_._unu ___ ud_l_n_i) ______________________________________ ? ____ __ 1 Worx th&n the averlio 2 Same 1 S 3 Bell«

1 19 Tran!f'Oruuonvelllclo~Yh.avo (lot.lwnllDI 0ifoDnealld91f9 or more)

19 i I Blcyclo H 2 Jo..udaJdoUt I 1--________ ~3~M~O~IO~~~~~I_O __________ ~t=j== ______________ 4 __ C_OI_UM ___ lru_b_wU __ l_~ __ rr __ nK __ k ____________________ __

~ ZO House (maIn malenal/tho mosl)

B 0

~ I

I I

1 Bamboo 2 Wood J Stone

21 Floor (maID malenal/tho moll) 1 Clay

2 Cemcnl

J Tllo

I Guoltno

3 Dle&el

23 II molher 10 keep flrruly lavalory

2 Pelromu

"' F 1C:'Clnclly

I No defealloD OUL\lde of Ihe house

3 Yes but useless

2 No defecallon the olhrr

4 Yell usefull

24 MIlO sou~o of dnniklni waler

I Wlter nvcr

3 Well 2 Water dnniklni IOU~O 4 ImlullOnal waler .upply

25 House beloni'"l 1 Not pel"lOnal beloni'"i 2 Rent

3 Self beanilnl

[IJ.[IJ 26 The WIdth of tho howe M2

27 Land/field 1 No

28 RIce field 1 No

29 The WIdth nce field acre

30 FIsh field 1 No

J I The WIdth of fish field acro

32 BOlt I No

2 Yes

2 Yes

2 Rent J Owner

[IJ·rn 2 Rent J Owner

[IJ CD

ID COMMUNICATION (No 33 sId No 36 cln be &sited to locil Idm,"l5lraItOn)

33 Dlstallce from house to He (In lubdlslncl) (Km)

34 DI51a1lce form house to nuresl ho~pltal(Km) 35 Trln<portul umum Ie PKM

L __ _

I None 2 There I' .elJ 1m/dlfficull

J Anyllnle 11&)/nIGnl)

:0 I

0 21 I

0 22 \ I

0 231

0 24 I

0 1.5 I I

fI U 27 I

0 28

o 30

D J2

I I 1

jl I

35 I L-J 1

I - J

• I - ~. - - - - -<-

~

~

/

36 Public trarup<>natlon to hospital

1 No 2 Then! II, seldomldlfricull 3 There 11 every IJme (day and n1iht)

37 Old mother look at TV 1 No, Delver

2 Y CII, look althe DClibbor •

3 Yea her own 3S Did mother h8~ 10 the radiO

1 No, never 2 Ye'J. lir ten to the ne~ghbor I B

3 Yea her own 39 Did mother rea.a the DC'Wiplper In the lut 3 month

3

1 Never 2 Severaillme./moolb 3 Several hmealwcelr. 4 All thc lime

40 Old mother read rN,lUlne In !he lut J month 1 Never 2 Several hmea/month 3 Several II mea' weci: 4 All the tune

'E FAMILY

I 4\ l'oIumbc:r or hou.'Chold mcmbc:r penon I

I 41 Are you now pre,nant I No 2 Yes

4) 1I0w man, lime the let pre,nant

44 lnfant Jeath Iner uunni the lUI year (I.e month, wnlc 0 If never)

45 Numbc:r of live child Incluulna who life out Iide penoD

46 Number or live child live Ul thll house penon

F OBSTETRIC IIISTOR Y

"" PREGl'oIANCY MODEOF SI rE OF BIRTI{ .r DELI .... ERY ,DELIVERY ATIENDANT

~ fcrm "'",_ .. rerNtur IV=:" I I ItOI ,ul 1 DOCTOR

" ~ur 2 op ckl I 2 \lC.~h Centre 2 MIDWIFE. .. A rt\&l 1 SC ) lIome ) TBA

I I

I I

I

I

I

I I I

I

I

I L I - -- - -

..

0 36

o 31

031

0 19

D oW

8 41 42

0 41

0 44

0 4S

0 46

----ALiVECIlILU F .... D CHILt

Ale (yn) "Ir .,n) (0- dud J - • ·e

ch,ld I thud J

-

-

-

4

~ ~ ~

~ I I a. RlSK FACTOR (filled UI for the hlltory of the lut delivery)

- 0 1 103 Younapnrna 1 Yea 103

(gravlCia I With !.he I~ ..s. 16 yean) 2 No I t I

104 Elderly pnau 1 Yel 0 ,

(jravlda I With the lie L 35 yesn) 2 No 104 I I

I 105 Elderly pnau I Yel 0 (gravuia I liU:r L 4 yean mamed) 2 No IDS

106 Secunciary elderly pmm 1 Yel 0 (youngCllt child 2. 10 yean) 2 No 106

107 YoungCIIlchlld < 2 yean I Yel 0 2 No 107

~ 108 Grand MulllpanlY 1 Yea 0 (already dehve~ mo", thAn 4) 2 No lOa

" 109 Lowhelghl~ 145cm 1 Yes

0 2 No 109

110 Bad obslelnc hUlory 1 Yes 0 2 No 9 Don t know lID

I' PreVIOU! vaginal operative delivery (forceps Vlcuum othen)

~ 1 Yes 3 Oul of cnlena 111 2 No 9 Don I know

112 PrevIous ue.sarea.a Sec II on

0 1 Yes 3 Oul of cnlena 112 2 No

113 Antepartum bleedln,

D 1 Yes 113 2 No 9 Don I know

114 Preeclamplla

D I Yell 114

2 No 9 Don know

lIS Eclampsil

0 I Yell liS 2 No 9 Don! know

116 Posl dale n I Yes L.J 116 2 No 9 Don I know

117 IT ImmunlUllon

0 1 Not yet/nol complete 1\7 2 Complete 9 Don t know

I ---~ - - = , - -- --- - --=-=---- - - - --

/ 5

118 MalpresentatIon

D 1 Yea IJI 2 No 9 Don lknow

I 119 Twm preiJW)CY 1 Yet 0 2 No 119

I J 20 HydramnlOD 1 Yel D

I

2 No 9 DOD lknow 120

121 Med,cal d,seue (WHO - ICO) 1 Yea 0 2 No 9 Don llaJow 111

122 Inlra ulenne fetAl death 1 Yea D 2 No 9 Don tknow 122

H DELIVERY HISTORY HI A."iTENATALCARE (Dcllvcn:dMothcn AUE 1992 - Apnl 1993)

123 Do you have anlClUui ure ( If never, fill 0 )

0 ye.! to HOSPITAL tllne

0 yea 10 rOLINOES lime

)'e.! to POSY ANOU lime 0 ye.! to HEALTH CENTRE lime 0

I 124 \Ion en are you be eurruned ror the finl IlIne 0 I 1 Tnrnuler 1 2 Tnrnuter2 3 Tnme.ster 3 124 I I 125 "''lien the lUI lame be euarruned

1 Tn rnc.ater 1 2 Tnrnuler2 3 Tnme.sler 3 1 0 125 ~ Tnrnea~, l 2 , Tnme.slrr 1 ) 6 Tnme.sler J ..

126 COST FOR ANTENATALCARE

POUNDES \

POSYANDU HEALTH CENTRi HOSPITAL

• Tnnap fee IX pp I 11 ! ! I I I I Eum fee IX I 1\1 I ! I I I I

! I MeJ +other J I III I I I I 1 I \ TOTAL COST 1 X II III I I I I I

~ , . I

• -~

130 1M melhod of .... ymc:nt 1 CL\h 2 Inlurance 3 Matenal

-- -==- - ~-

51

I

6

•

III Do you know berore now mucll the Iraruporull()f1 coel 10

POUNDES Yea 2 No

POSYANDU Y~ 2 No

HEALTI1 CENTRE Yea 2 No

HOSPITAL Y~ 2 ~o

A. ... TENATAL REFERRAl. 132 Are you refernd 1 (rill III the bell til V>'l III 0 I r ,0\1 are not re (etnd )

Rtf~fT't1

I TBA

~ FROM

2 MIDWIFB TO J POSYANOU TO • HEALTIfCENTRE Th.lullO S HOSPITAL I i i ! I

133 InulullOn of preinancy rdernl

134 Tnme.!ler I referred 7 Ye.

13.5 Tr1ITlt'~ler II referrro 1 YM

136 Tnmesler III referred 7 Ye.

137 Did molher come 10 the referral 1,le 7 1 Ye.

138 The (.rheal distance (rom the house to the referr.l .. le

139 Total cost for the rdemJ pfOCZSl TnnsportalJOtI v v

MedicIne & olherl

ToLtI COil

140 Trant;portlltonused Tradlllonal vehIcle Pubhc Iransportlllon/renl Personallransportallonlborrow

Ambulance

Y~

y~

Yea y~

2 No

2 No

2 No

km

Rp

Rp

,.

Refer b.ck

th-, I I i

ICO I

2 No

2 No 2 No 2 No 2 No

Rp

i

I

I

I

141 WIlling 10 be referred becau$e Forced by heahh personel 2 AdVIsed Ihe husband/retallve 3 Self awerenes!

142 If she dldn I came 10 Ihe referral Slie

1 No money 3 Reliuse

------- -

(Ii II no \J 7 I f answered no)

2 Trm.portlllOndlf(jculh~ 4 Olher I (menllOn)

0 0 0 0

1m III

0 1]4

0 IU

0 136

0 137

OJ 138

D

o \42

\

H 2 PROCESS OF DELIVERY

1"3 Dale of dehverv I I I I I I I 143

1"4 Wu the mother referT'CCI 0 1 No --> dlrecl to Dumber 141 14-4

I 1 Yea

\ 145 The reueon of Ullrlplrtum referral (mcnltoo) 0 1 Bec.aUle of Oblt.elnc: problem 2 Becauae non Obstetnc problem (olher dlae&Se) 145

I

3 CombUle 1 + 2 I I" r '" c.. L ~..2.... 1 • 1

.---,.<

I 146 DId the mother ,0 to the re{ernl aile

0 \

I No 2 YCI 146

I 147 Where did the mother dell ... er the boIby

1 Home 2 TBA I holUe 0 3 M IIh"'l (e I bouse .. Pollndea 141 S Health Crnt.er 6 HOlpltal

148 Tran.por1 u'CIJ 10 Ibe tmt.b Ille

D 1 Trad,llonal"'ch,c1e 1 Yes 2 No

2 Public 1r.n'poruhon/renl 1 YCI 2 No D ) Pe~1 Iralllporuhonlbonvw 1 Yc. 2 No D .. Ambulance 1 Yc. 2 No D

149 v.. ho " your blr1h IlIc.,JanI I TBAlolher

0 ., MHhvlfe 149 .

J Doctor

\ ISO HO .... ls the mode or bib}' bom

1 SponLll\ clon 2 \ I.,nal op dell ... ery 0 150 J SeeIIO CM.aarcu

l.51 Delal) or loul 6eln-cry Coel

• T ranspotUhoa " " fir

Dell ... ery ~r

MW'CIM Rp

TOIaI co,1 Rp

J ... ~~~~ f~~~ __________ --------------

-

I---------~ 1 ~ 2 How II the condillon o( the mother after dellHa..

0 Molherdled 2 Sl':'" "orold1~Y

3 Healthy - > dU'eCt to numhoer 156

1 S) 'Ilrn..t und of dlleue ( (rnc:nlloa)

1H \Vhere did the...."mcn 10011; for lre.atmmllthe hllhell .... l) 1 Alone 2 To TBA J To ItlJd,.,ve .. To healtlt centre

S To docLOt' 6 To hotrlW

155 Hospilal.lay wben the "'omen I.ck (dAy')

(wnle 0 If the women "'U not bmpltal hu)

156 Co nUl lion the baby bom 1 Deatb 2 B.by IIell; Of Wlknowa

3 lle.althy-> dU'eCttono 160

I 57 DI~ase of the baby

2 Con ., 1J.:31.0n

Yea 2 No 1 Ictenc

.. Fevu

158 Where did the baby look lor treatment (the hlEhealevel)

I Alone 2 To TBA 3 To nudwlve/nune

S To doctor

.. To health centre

6 To ho~pltal

159 Hospital llay when the baby IICIc (day.) (wnte 0 If tbe blby wu nol hosplLalltu)

l PUERPERAL HISTORY (until 42 day. poll ram.m)

(lill 0, Ir molheror baby dIed)

160 How'l lbe health ~ndilion of mother

I Bid 2 Good - > duecllo number 16]

161 DIsuse of molher (mention)

162 Where did the women look lor treatment (the hl£he.s level)

I Alone 2 To TBA

3 To nuo"'lle/nurse S To doctor

4 To health centre

6 To hospilai

163 How IS the I.clatlnl hlslory of the baby

Bcglnlni II days olu The frequency of nuntni limes

Until days/onenth

(fill In With 99 II not brea~t fiuang)

---- -- --------:====-

151

15] \

0 154 I

0 US

0 iS6

o ISS

o 159

16(

[J 16

'63

I

11 l I I

I I

I I I I

I

I

t I I I

I I I I

I

,

I

I I

I

I I I I ,

;~

1~ Howu the condilion of the baby

1 Bad 2 Good -> dlm:t1y to number 167

165 What kind of dlJe&Je Convulsion

9

I Yea 2 No 3 Fever

4 Common cold and couah

166 Where did the baby loolc for treatmelll (the hlihea level)

1 Alooe 2 To TBA J To rrudWlfe/oune 4 To Health Centre 5 To dOClOr 6 To Hospital

IISTORY AFTER 42 DA YS POST PARTUM (fill 0 If mother or baby died)

167 Old the women wa.l flrrul), pllrullni methode

lfiS COnlrlc~rtlve method u..:!

I Safe pcnooe (calendar Iyllem)

J 0,,1 PIli 5 Implant

7 Tut>ectomy

169 How IS the ConOllion of the baby now

I Bad 2 Good

No - > direct to no 69

2 Yea. II > 40 daya posl par1Um

3 Yes II < 40 day. potl par1U1D

2 Condom

4 InjectAble 6 IUD 8 Vaseclomy

170 I. Ihe baby Ulrruned ~Iularly (ch~ the mosl oOen done) I No - > dll't!Clly 10 num~r 172

2 Vea to POIyanciu 3 Yea 10 rrudwlfe

4 Yea to he:&lthcallre 5 Yea lO hospItAl

171 How mM},llInaltllrruned (utllIl Arnl 1993)

172 Old Ihe bab}' lei ·J(tr~feedlng

o No "",nIh,

17) Docs the hany Ikl'le ~ vMS cord

1 No 2 'r ea

174 Doea the hahy ,et I mmunllAlion ahead y

1 None II .11 2 Yea not complete

J ) ea comr1ele 4 Plnpuma

D ]~

o 166

D 161

o 168

0 169

0 170

0 171

0 172

0 173

0 174

I

, :

~

..

10

1

0 17.5 , I - I I

11,5 In the lUI J month! .. the baby III

I Yea once

J Ya,lhrnea

2 't e3 twice

4 No -:> I,hrcctl} to number 118

116 What kind o( dlJe.Ue 1 Coovul'loa

>--

I Yet 2 No >--3 Fever

tJ ~ ______________________________________________ ~.,~C~Q~~d~A~u.&~h ________________________________________ __ I 177 ..... 'here did the baby look (or treatment (the iulhealle"el)

1 Alone 1 To TBA 3 To nud"lfe/nune 4 To Health Centre S To doclor 6 To HosPllaJ

l HISTORY OF MORT AUTY (If mortality taken place dunn, the prrinancy and Jdlyery

from Au,u.~t 1992 "'pnll993) 11! v,'ho doe.a the mother die I f'rrinant month

2 Dellyery

179 Where did II h.r~n

1 Homo 4 M Idwi fe • hoUJe

2 TIlA • hou~ .5 Health centre

(0 - No)

( 0 - No 2 - y,..)

(000 - No)

J Death on the mad 6 Doctor pnYlte p ... Chc.e

0 In

rrB I

I

0 17' I

~: __________ ~7~liospllituU~ __________________________________________________________________ ___

I 1 SO Su5pt:'Ctod caUJe of maternal mortality (mcnllon)

181 Irthe lUI baby died When 7 (rill If the luI baby died) I Inl ... uu=nne 2 Inlranll&.l J Died ft the 1,0 .s. I week IOer born 4 Died I&e day.

182 \\onere did It hlppen I Home S Health centre

2 TBA. howe 3 Dealh on the rOld

6 Doclor pnYlle prachce 7 HospItAl

183 Suspected cause of death I Convulsion

4 M ,dwde • hou~

I Yes 2 No J Feyer

4 Common cold and coueh

L SYSTEM OF COST

.J ....

IS4 Is there ~y lid for the Irealment c(\sl1 I No - > 'lop Inlervlew

18,5 I f any lid where IS II como (rom 1

2 Yes

I ProYlder 2 Figure In the comu",ly J Flnuly/fnend! 4 Dana 5ehat/lnsurl11ce

180

[JJ 111 I

o 1811

0 I 0 0

I I

0 I

I

0 184

I 0 ISS I

I

/ t

) ~

11

,\DOlT lONAL QlFC;TIONS It-. TIlE INTEH\ Er-.TI0N AREA

M SCREENING ACTIVITIES B' CADRE 186 Were you contacted by P~h Cadre about your pregnancy

1 Yes 2 No 0186

187 How many times ?

188 What was the last color of the color code before

189

190

191

the delivery ~

1 Green 2. Yellow 3 Red

Advice for delivery a Who has given the advice to you about the

place and blrth attendant 1 Csdre 2 TBA 3 Midwife

b

c

Did a

4 Doctor 5

Where was the adviced Mother's home

3 Midwife's 5 Health Centre

Herself 6 Family

place of delivery 2 TBA I a home 4 Village birthing 6 Hospital

hut

who was the adviced birth attendant 1 TR" 2 Hldwlfe 3 Doctor

you deliver On the adviced site

'tes 2 No b What are your considerations in chosing the

site of delivery

Have

" b If

1 Match to the 2 According to the color code

3 Coat 6 Tradition

you beftn referred 1 'rea

you hl\d ever been 1 ("dre 2 4 Doctor 5

advice 4 Distance 6 Others

2 No

referred by whom TBA 3 Herself 6

THE INTERVIEW FINISH, THANK YOU

Midwife Family

0 187

0188

0189.,

0189 I

0 189"

0 190

0190

LJ 191-

0 191

51

APPENDIX 2

Risk Factor Analysis by Total Score and Risk Group for Probolinggo Implementation (District = rural, and Municipality)

Table 1 DIStributIOn of RISk Factors with Total Score/RIsk Group by the RISk Scormg S\ ... tem Probohnggo DlStnct (Rural)

Tdble 2 DL ... 1r1butlOn of Double RISk Factors with TT, Total Score/RISk (yroup b\ the RL"'~ ~lormg System, Probohnggo DIStrict (Rural)

T dble 3 Dl ... 1r1butlOn of Double RISk Factors, Total Score/RIsk Group by the RI ... k ~conng 10,\ .. 1 em Probolmggo DlStnct (Rural)

T dble 4 Dl~rlbutlOn of Three RIsk Factors with TT, Total Score/RISk (yroup b) the RL"~ ~cormg ~ystem. Probohnggo DlStnct (Rural)

Table 5 DL~rlbutlOn of Three RIsk Factors Total Score/RIsk Group by the RI ... k ,",cormg ~) ... 1 em Probolmggo DIStrict (Rural)

Tdble 6 DL ... 1nbutlon of Four RLlik Fdctors with TT, Total Score/RISk (.roup b\ the RL"~ "conng S\~em Probohnggo DIStrict (Rural)

T dble 7 DL ... 1nbutlon of tour RL ... k Factors with TT, Total Score/RISk (yroup b} tht' RL'" ~conng ~)"'1em Probohnggo DlStnct (Rural)

Table 8 DL~nbutlOn of RL .. " F.actorli, Total Score/RIsk Group b} the Rllik ~conng System Prubc:,(muo \tuOlclpdht}

Tablt' 9 Dl~nbutum of T"o R&k Fdcto~. Total Score/RIsk Group b} the RIsk ~conng ~)'lem Probolmggo \tuOlclpdht}

T dble 10 DL ... 1rlbutaon of Three Rl"'~ Factors, Total Score/RIsk Group b} the RL ... k "cormg "', .. tern Probolmggo \luDlclpahty

T dble 11 DL~nhutlon of Four RISk Factors, Total Score/RIsk Group by the R&k Scormg ~\~em Probolmggo MUOlclpalIty

Table 1

NO

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20

DIstrIbutIon of RISk Factor WIth Total Score / RISk Group by the RISk ScorIng System

Probollnggo Dist net (Ru r,ll) -------- ------- -- -r------ -----,-------

N Age / Single RlSk Factor 7169 % Pan t y Score/Rlsk

n 2 GtOUP

RISk Factor

Young Prunl GravIda (Young Pr Iffil ) 96 1 34 0 Elderly Prunl GravIda (Elderly PrIml ) 31 o 43 28 6 / H R Grande Multlpara* (Grande Hultl) 165 2 30 76 8 / H R Over 35 years (OVer 35) 12 o 17 0 Youngest ChIld < 2 years (YC 2) 263 3 67 248 6 / H R Youngest ChIld ~ 10 years (YC 10) 237 3 31 175 6 / H R Low HeIght ~ 145 em (Low HeIght 145) 89 1 24 42 6 / H R Poor ObstetrIc HIstory (Poor Obs H) 183 2 55 149 6 / H R HIstory DIffIcult BIrth (H Dlff BIrth) 10 014 7 6 / H R PrIor SectIon ( Pr lOr Sect IOn ) 5 o 07 4 6 / H R Bleecilng (BleedIng) 16 o 22 13 10 / H R Eclanpsla (Ekl) 0 0 Mother's dlsease (Moth dIsease) 25 o 35 20 6 / H R Preec lanps la (Pre Ekl) 20 o 28 16 6 / H R MalpresentatIon (Halpres ) 28 o 39 19 6 / H R twIn Pregnancy (twIns Preg) 18 o 25 12 6 / H R Hydr amrnon (Hydram) 3 o 04 3 6 / H R IUFD (IUFD) 10 o 14 7 6 / H R Post Dates (Post Dates) 15 o 21 12 6 / H R TT lmunltatlon (TT) 741 10 34 561 6 / H R

Total 1967 27 44 1392

-

Age / Panty Score/RIsk

4 & 6* Group

96 8 / H R 3 8 / H R

89 8 / H R 12 8 / H R 15 8 / H R 62 8 / H R 47 8 / H R 34 8 / H R

3 8 / H R 1 8 / H R 3 12 / V H R 0 5 8 / H R 4 8 / H R 9 8 / H R 6 8 / H R 0 8 / H R 3 8 / H R 3 8 / H R

180 8 / H R

575

Women wIth sIngle rIsk factors were 1967 (27 44%) wIth the total score 6 (66 2%), 8 (32 9%), 10 (0 7%) and 12 (O 2%) The HIgh rIsk women were 99 8%, and Very hIgh rIsk women 0 2% The hIghest percentage on TT lmunlsatlon 10 34%, than the youngest ChIld < 2 years 3 67%, the youngest ChIld) 10 years 3 31% The others rIsk factors were less than 3%

fJ

Table 2

NO

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

D1StrLbutlon Double Rlsk Factor WIth TT, Total Score / RlSk Group by the RIsk Scor lIlg System

Probohnggo DIstrIct (Kur.ll)

N Age / A ge / Two RISk Factors 7169 % ParIty Score/RIsk Pd ray Score/RIsk

wIth TT n 2 Group 4 & 6-- Group

TT+ Young Pr l.ffi.1 9 013 0 9 12 / V H R TT+ Elder 1 y Pr:unI 3 o 04 3 :0 / H R 0 TT + OVer 35 2 o 02 0 ") 12 / V If H TT + Grande Hultl* 62 o 86 15 12 / V H R 4 7 14 / V Ii R TT + YC 2 27 o 38 22 10 / Ii R '> 12 I V H k TT + YC 10 30 o 42 19 10 / Ii R 1 1 12 / V Ii H TT+ Low HeIght 145 12 o 16 8 10 / H R 4 1/ / V H k TT+ Poor Obs H 22 o 31 20 10 / H R ") 1 .' V It k .. TT + H Diff Buth 1 o 01 0 I.'

I " II I~

TT + BleedIng 3 o 04 3 14 / V It R ( J

TT+ Ekl 1 o 01 1 14 / V H R 0 T'I'+ Hath DIsease 6 o 08 5 10 / H R I ,J II k T'I'+ Pre Ekl 3 o 04 3 10 / H R 0 TT + Halpres 3 o 04 1 10 / H R 2 l. / V Ii H T'I' + TwUlS Preg 3 o 04 1 10 / H R 2 12 / V H H T'I' + I UFO 5 o 06 2 10 / H R 3 12 / V H H TT+ Post Dates 3 o 04 3 10 / H R 0

--195 272 106 8 9

--

Women wIth double nsk factors (T'I' and other risk factor) were lq~ (2 72%) Wllh th~ total score 10 (44 6%), 12 (29 2%), and 14 (26 2%) The HIgh risk wOfTlt:ln Wei e 44 t,'t. dud Very hIgh rlsk women 55 4% The percentage of women wIth thIS two rl~k tactul~ WLIL leJ~ than 1%

Table 3

NO

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Dlstrlbutlon of Double Risk Factors, Total Score I RISk Group by the Risk Scoring System

Probollnggo Dlstnct (HII ral ) - ---------~.

N Age I Agel Two Risk Factors 7169 % Panty Score/ RlSk Panty

n 2 Group 4 & 6* -- -

Grande Hulti*+ Low Height 145 1 o 01 0 1 Grande Hulti + Poor Obs H 4 o 06 0 4 Grande Hult1 + H D1ff BIrth 2 o 02 0 2 Grarxle Hultl + YC 2 7 o 09 0 7 Grande Hulti + YC 10 12 o 17 0 12 Grande Hultl + Blee(hng 1 o 01 0 1 Grande Hultl + Moth Disease 2 o 02 1 12 I V H R 1 Grarxle Hultl + Pre Ekl 1 o 01 0 1 Grarxle Hultl + Halpres 2 o 02 1 12 / V H R 1 Grarxle Hultl + Twlns Preg 1 o 01 0 1 Grande Hultl t IUFD 1 o 01 1 12 / V H R 0 Young Pr Iml + Low Helght 145 3 o 04 0 3 Young Pr 1ml + Ekl 1 o 01 0 1 Young Prlml + TwlllS Preg 1 o 01 0 1 Young Prlml + IUFD 1 o 01 0 1 Elderly Prlml + Moth Disease 1 o 01 1 10 / H R 0 Elderly Prlml + Halpres S 1 o 01 1 10 / H R 0 Elderly PrlllU + IUFD 1 o 01 0 1 Elderly Prlml + Post Dates 1 o 01 J 10 / H R 0 OVer 35 + Bleedlng 1 o 01 1 14 / V H R 0 OVer 35 + Pre Ekl 1 o 01 0 1 YC 2 + P(X)r Obs H 1 o 01 1 10 / H R 0 YC 2 + Blee(llng 2 o 02 2 14 / V H 0 YC 2 + Moth Dlsease 4 o 06 3 10 / H R 1 YC 10 + P(X)r Obs H 1 o 01 1 10 / H R 0 YC 10 + SkI 1 o 01 1 14 / V H R 0 YC 10 + Moth Dlsease 3 o 04 2 10 / H R 1 YC 10 + Pre Ekl 1 o 01 0 1 YC 10 + Halpres S 4 o 06 2 10 / H R 2 YC 10 + IUFD 1 o 01 0 1

Scor~/Rlsk Group

14 I V H R 14 I V H R 14 I V H R 14 I V H R 14 I V H R 18 I V H R 14 I V H R 14 I V H R 14 I V H R 14 I V H R

12 I V H R 12 I V H R 12 / V H R 12 / V H R

12 I V H R

12 / V H R

12 I V H R

12 I V H R 12 I V H R 12 I V H R 12 I V H R

- - ----

------

31 Low HeIght 145 + Ekl 1 o 01 0 J It. / V II 1-<

32 Low HeIght 145 + Poor Obs H 3 o 04 3 10 / H R 0 33 Low HeIght 145 + Bleecllng 1 o 01 0 1 Ib / V U H 34 Low HeIght 145 + Halpres S 1 o 01 0 1 12 / V H H 35 Low HeIght 145 + Moth DIsease 1 o 01 1 10 / H R 0 36 Low Helght 1.5 + Twlns Preg 2 o 02 0 2 12 / V H H 37 PoorObs H + H Dlff Buth 1 o 01 1 10 / H R 0 38 Poor Obs H + PSc c/~ 1 o 01 1 10 / H R 0 39 PoorObs H + B1e6(11ng 2 o 02 2 14 / V H R 0 40 PoorObs H + Moth Dlsease 1 o 01 1 10 / H R 0 41 PoorObs H + Pre Ek1 1 o 01 0 1 10 / H R 42 PoorObs H + Halpres S 2 o 02 2 10 / H R 0 43 PoorObs H + Halpres L 2 o 02 1 10 I H R 1 10 / H R 44 Poor Obs H + Twlns Preg 1 o 01 0 1 lU / II R 45 Poor Obs H + Hydram 1 o 01 1 10 / H R 0 46 PoorObs H + IUFD 2 o 02 2 10 / U R 0 47 H Dlff Buth + Pre Ekl 1 o 01 1 10 / H R 0 48 Bleedlng + PSC 1 o 01 0 1 14 / V 11 R 49 Bleedlng + Pre Ekl 1 o 01 1 14 / V U k 0

50 Moth DIsease + Pre Ekl 1 o 01 1 10 / H R ()

51 Moth DIsease t Halpres L 1 o 01 0 1 III I II k 52 Moth D1sease t Post Dates 1 o 01 1 10 / H R ()

53 TwIns Preg + Hdlpres S 3 o 04 2 10 / II R 1 lu / H k 54 Tw1ns Preg + IUFD 1 o 01 1 10 / H R 0

55 TwIns Preg + Post Dates 1 o 01 0 1 ill / 1\ R 56 IUFD + Halpres S 1 o 01 1 10 / H R 0 57 Post Dates + H D1ff Buth 1 o 01 1 10 / H R 0

--- -

Total 100 1 39 43 'J7

Women wIth double nsk factors grand multlpara w1th other risk taLlor 34 (34 0%) YCILUIY prlll\l wlth other r1sk factor 6 (6 0%), elderly pnm1 & other Ri- 4 (4 0%), OVt!1 ~'J YtMr. & other RF 2 (20%), youngest ChIld < 2 years & other RF 18 (180%) luw hel()tlt ... 'Itllt'l H~ q (9 0%), Poor OH & other RF 14 (14 0%), bleedlng & RF 2 (2 0%), IT¥>thtHS dlSt l,t j (j 01, tWIns & RF 5 (5 0%), and others 3 (3 0%) Women with total SCOlt! 10 (3q 0%) I ('lJ Ot) 14 (14 0%), 16 (2 0%) and 18 (1 0%) The HIgh rIsk women were 39 0% arid Vt-'lY tll.)tl 11.k

women 610\ The percentage of women w1th thIS two nsk factors welt! les::. thdll 1'f

Table 4

NO

1 2 3 4 5 6 7 8 9

10 11 12 13

DlstrlwtlOn of Three RISk Factors wIth TT, Total Score / RISk Group by the RISk Scoring System

Probollnggo DIstr lct (HI! r II ) - - - - ---- -- --,---- --- - - -- - -

N Agp / Age / Three RISk Factors 716q % Pan ty Scorp/Rlsk Pan t y

TT -+ Gr arvie HUl t 1*-+ YC 2 TT -+ Grande HUltl -+ YC 10 TT -+ Gr ande HU It I + Poor Obs H TT -+ Grande HUH I -+ Rleedlrlq TT + Gr ande Hu It I + Hoth DIsease TT + Grande Hultl + Halpres S TT -+ Grande Hult I .. TWIns Preg TT -+ Poor Obs H + Hath Disease TT + Poor Obs H .. Pre Ekl TT-+ Young Prlml .. Low Height 145 TT-+ Post Dates -+ YC 2 TT+ Post Dates .. Pre Ekl TT+ TwIns Preg .. Hydram

Total

n 2 ----

2 o 03 0 3 o 04 0 3 o 04 0 1 o 01 0 2 o 03 0 1 o 01 0 2 o 03 0 1 o 01 1 1 o 01 1 1 o 01 1 1 o 01 1 1 o 01 1 1 o 01 1

20 o 28 6

Group -- ---

14 / V II 14 / V H 14 / V H 14 / V II 14 / V H 14 / V H

R R R R R R

4 & 6*

2 3 1 1 2 1 2 0 0 0 0 0 0

14

- -

~)core/Rlsk

Group

18 / V H R 18 / V H R lfl / V H R 2L / V H R 18 / V H R 18 / V H R 18 / V H R

Women wIth three rIsk factors (TT and 2 other rIsk factors) were 20 (0 28%) wIth the total score 14 (30 0%), 18 (65 0%), and 22 (5 0%), all women were Very hIgh rIsk The percentage of women on each of these three combIned rIsk factors were less than 1%

Table 5

NO

1 2 3 4 5 6 7 8 9

DIstr.lb.Itlon of Three RISk Factor, Total Score / RlSk Group by the RISk ScorUlg System

Probohnggo DIstrIct (HlJ r .... l) - ---

N Age / Three RISk Factors 7169 % Panty ~core/Hl!:>k

n 2 - - -

Poor Obs H + Grande Hultl* + Malpres S 1 o 01 I 10 / V H H Poor Obs H + Grande Hultl + IUFD 1 o 01 0 Poor Obs H + Young Primi G + Low HeIght 1 o 01 0 Poor ObstetrIc H + BleedIng + IUFD 1 o 01 1 18 / V If f< Poor Obs H + Pre Ekl + Moth DIsease 1 o 01 1 14 / V H R Poor Obs H + Pre Ekl + Halpres S 1 o 01 1 14 / V U f< Grande Hultl + H Dlff BIrth t Low Helght 1 o 01 1 1 tJ I V II k Grande Huitl + H Dlff Birth t Pre Ekl 1 o 01 1 10 / V tI k OVer 35 + Low Helght 145 t Post Dates I 0

-- --Total 9 o 12 b

I AYt / Pan t y \ ure/Rlsk 4 & 6·

- ---

18 / V H R 18 / V H R

It.> I V H R

J

Women WIth three risk factors poor OH grand WI th other 2 risk t.1( t(,1 J ~ I Lf, ,~) Y' u .. t mid t llhJ[ 1

WIth other 2 rIsk factors 2 (22 2%), and over 35 years wlth 2otbt!! rl'.k tit t", 1 (11 U) W""lltTl With total score 14 (22 2%), 16 (44 4%) and 18 (33 3%), all wcroon wt!re V~ry tlllJh r u"k Ttlt! ~Jt:!rl~ntdlJe of women on each of these three combIned r1sk factors were less thdfl 1%

Table b

NO

1 2

DIstribution of Four RlSk Factors wIth TT, Total Score / RISk Group by the R 1sk C)a}f1 ng System

Four RISk Factors

TT + Grande Hultl *t Hath TT + BleedlnQ + Halpres

ProbollnggD Dlstnct (RII r 11 )

Dlsease + Pre Ekl S + Elderly Pr1mI G

N 7169

n

1 1

o 01 o 01

Agel Parlty ~corel RISk 4 & 6~ Group

1 1

70 / V II R n/VIIR

t-----L-.---------------------------Total 2 o 02

The total score 22 was the h1ghest total score of all the women wlth a SIngle or combIned r1sk factors The women wlth 4 r1sk factors were only 2 They were TT wlth 3 other rIsk factors The total score of each women were 20, and 22 Both women were Very HIgh RiSk

Table 7

NO

1 2

DIstrIbutIon of Four RISk Factors wIth TT, Total Score I RlSk Group by the RISk ScorIng System

Probolinggo DIstrIct (Kur~1) - -,-

N Agel Four RlSk Factors 7169 % ParIty ~lorel RIsk

TT + Grande Multl*+ Moth DIsease + Pre Ekl TT + Bleedlng + Malpres S + Elderll PrIn

Total

n

1 G 1

2 ---

o 01 o O}

4 & 6* Group

1 1

20 I V H R 22 I V H R

o 02 2 -- - ----____ --J

The women wIth 4 rlsk factors were only 2 total score of each women were 20, and 22

They were TT wlth 3 other rIsk Both women were Very Hlyh Hlbk

factors The

Table 8 Dlstrlbutlon of Risk Factor, Total Score / Rlsk Group by the Risk Scoring System

Probollnggo HlDuClpahty ---

r---- - -T---N Age / Age /

NO SIngle Risk Factor 1206 % Panty Score/RIsk Parlty n 2 Group 4 & 6*

1 Young Pr lOU GravIda (Young PrIm1) 2 o 17 0 2 2 OVer 35 Years (OVer 35) 4 o 33 0 4 3 Grande Multipara * (Grande H ) 34 2 82 0 34 4 Youngest Chi ld < 2 Years (YC 2) 45 3 73 42 6 / H R 3 5 Youngest ChIld ~ 10 Years (YC 10) 31 2 57 18 6 / H R 13 6 Low Height ~ 145 em (LH 145) 4 o 33 3 6 / H R 1 7 Poor ObstetriC History (P Obs H) 13 1 08 12 6 / H R 1 8 Pr lor Sect Ion (P sect 10) 2 o 17 2 6 / H R 0 9 Blee<i1ng (BleedIng) 4 o 33 4 10 / H R 0

10 Mother's DIsease (Moth DIsease) 4 o 33 3 6 / H R 1 11 Preeclanpsla (Preekl) 6 o 50 5 6 / H R 1 12 Halpresentatlon (Halpres ) 6 o 50 5 6 / H R 1 13 Twlns Pregnancy (Twm Preg ) 3 o 25 3 6 / H R 0 14 Hydramrllon (Hydram ) 1 o 08 0 1 15 Post Dates (Post Date) 3 o 25 3 6 / H R 0 16 TT IIIIlID.l tat10n (TT ) 12 1 00 9 6 / H R 3

Total 174 14 43 109 65

--

Score/RIsk Group

8 / H R 8 / H R 6 / H R 8 / H R 8 / H R 8 / H R 8 / H R

8 / H R 8 / H R 8 / H R

8 / H R

8 / H R

Women wlth slOgle rlsk factors were 174 (14 43%) wlth the total score 6 (79 9%), 8 (17 8%), and 10 (2 3%), all women were Hlgh r1sk The hlghest percentage on the youngest ChIld < 2 years 3 73%, then grand multlpara (2 82%), and the youngest Chlld ~ 10 years 2 57% The other rIsk factors were 1% or less

Table 9 DIstr1butlon of Two ~sk Factors, Total Score / RISk Group by the RISk ScorlIlg System

ProbolLnggO ~cIpallty

N Age / Age / NO Two RISk Factors 1206 % ParIty Score / RI sk ParIty

n 2 Group 4 & 6~ ---

1 Grande H 11 + YC 2 2 017 0 2 2 Grande H + YC 10 5 o 41 0 5 3 Grande H + P Obs H 1 o 08 0 1 4 Grande H + Hath DIsease 1 o 08 0 1 5 Grande H + Preekl 1 o 08 0 1 6 Grande H + TwIn Preg 1 o 08 0 1 7 Grande H + TT 5 o 41 0 ')

8 'l'T + YC 10 4 o 33 3 10 / H R 1 9 'l'T + YC 2 3 o 25 3 10 / H R 0

10 YC 2 + P Obs H 1 o 08 1 10 / H R 0 11 YC 2 + Halpres 2 o 17 2 10 / H R 0 12 YC 10 + Moth DIsease 1 o 08 0 1 13 YC 10 + Preekl 1 o 08 0 1 14 YC 10 + TwIn Preg 1 o 08 0 1 15 OVer 35 + TT 1 o 08 0 1 16 OVer 35 + Moth DIsease 1 o 08 0 1

--31 2 57 9 22

- ----

Scure/RIsk Group

10 / H H 10 / H R 10 I If R 10 I H R 10 / If R 10 I H R l() I If R Il I V If I<

1': I V II H 1 ., I V II H I.' I V II H 1'1 / V H H 12 / V If R

- ------

-------

Women wIth double rIsk factors grand multIpara wlth other rlsk factor 16 (~l b%) TT wlth other RF 7 (22 6%), youngest clnld < 2 years wIth other RF 3 (q 7%) yc)unql. > t <. hi 1 d .> 1fI years wIth other RF 3 (9 7%), and over 35 years with other RF 1. (6 H) Womtu Wlttl tllLsl score 10 (80 6%), and 12 (19 4%) The HIgh rIsk women were 80 b% dIIL1 Very tll'JIi I I k W.IIII.,.

19 4% The percentage of women wllh thIS two rIsk fae tors were leb~ t h UI U

Table \0 DIstrlbutlon of Three RIsk Factor~, Total Score / RI~k Group by the Risk ScorIng System PTobolInggo MunIClpallty

-- ---" -·----r ----

N Age / NO Three RlSk Factors 1206 % Panty Score/Rlsk

n 2 Group

1 Grande H * + YC 2 t TT 2 o 17 0 2 Grande H + YC 10 t Hath Disease 1 o 08 0 3 Grande H • YC 10 -+ ?reekl 1 o 08 0 4 YC 2 t Hath Dlsease t TT 1 o 08 1 14 / V H R 5 YC 2 t Halpres t'IT 1 o 08 1 14 / V fI R 6 Hath Dlsease t Preekl t Halpres 1 o 08 0 7 Post Dates + Hath Disease t TT 1 o 08 0

8 o 66 2

- -

Age / Pan ty Score/Rlsk 4 & 6* Group

---

2 14 / V H R 1 14 / V H R 1 14 / V H R

1 16 / V H R 1 16 / V H R

6

Women w1th three r1sk factors grande mult1para other 2 r1sk factors 4 (50 0%), youngest ch1ld < 2 years with other 2 risk factors 2 (25 0%), mother d1sease wlth other 2 rIsk factors 1 (12 5%) and post dates with 2 other r1sk factors 1 (22 2%) Women wIth total score 14 (75 0%), and 16 (25 0%), all women were Very high r1sk The percentage of women on each of these three comb1ned r1sk factors were much less than 1%

Table 11 D1Str1butlon of Four RISk Factors, Total Score / RISk Group by the RIsk Scorl119 System

Probol1nggO ~cIpallty --

N Age / NO Four RISk Factors 1206 % Parity Score/Risk

n 2 Group

1 Grande H + YC 10 + Halpres + 1 o 08 0 Hath DIsease

- - -- -

Age / ParIty Score/RIsk 4 & 6" Group

1 18 / V H R

The women wIth 4 rIsk factors was only 1, a grande multIpara wlth 3 other r1sk fdctors was only 1, wIth the total score 18, as a Very hIgh fISk women

c '\

APPENDIX 3

Table 1: Maternal and Perinatal Mortality by Risk Groups for Probolinggo and Pasuruan

Table 2: Overview of Total Women, Births, Maternal and Perinatal Death for all Study Periods and Sub-Divided by Urban/RuraI for Probolinggo

\

Appt'ndl\ 3 ~hIU'lll lilt! PUlnatal Mllrulll\ h) RI\~ (HIlUP\ lor Pit IIld Pmt ~urvey (Prohohnggo and Pa~anl1n) 1nd Implcmcntallon Illhlr 1 IProhllllll/l./l.II' I a\t Ja\a I'N~ II~lJ \

l"-y!?t,!Ln-llQ 1'11'11 ru 11 n I"-ohohneeo \ ariable .... ~ Po ... .... e Po<;t Implementation

Total hlrths 94'i \ 711'i 6'i02 47H2 8415 Lme Births 9110 6951 6419 470'i 8215 SIIII Births 141 182 61 77 200 (-NO 113 114 42 33 161 Maternal Deaths 25 26 10 14 26 MMRIIOO (XX) I B 2M 'i H19 l'i'i 3 2974 1165 PMRf)(XX) T8 27 I 41 5 16 I 2 \ 0 4 \ I

Low Risk live Birth .. 'i444 1927 4152 28\8 5711 SIIII Births 4\ 51 26 20 77 FND 'il 47 17 l'i 94 Maternal Deaths 1\ 6 4 6 9 MMR/IOO 000 LB 238 8 152 8 963 211 4 1576 PMRllOOO TB 17 \ 25 I 103 12 3 295

IIIgh Risk Live Births 2818 2723 1842 1718 2384 SIIII Births 46 102 20 41 102 END 38 52 14 15 62 Maternal Deaths 5 14 2 7 12 MMRIIOO 000 LB 177 4 514 1 104 3 4075 5034 PMRllOOO TB 293 545 206 31 8 659

Very High Risk Live Births 1048 303 340 149 120 SIIII Births 54 32 12 16 21 END 23 15 7 3 7 Maternal Deaths 7 6 4 1 5 MMRIIOO 000 LB 6679 19802 10840 671 1 41667 PMR/IOOO TB 699 1403 57 3 1152 1986

~

~

AI'I'INIJIX I III I t.. 2

1 Number of mothers Singleton T"'1ns Triplet

2 Total births Singleton T",lns babies Triplet babies

3 Live births Singleton T",1ns bob1es Tr1plet babies

4 HHR/IOO,OOO LB

Singleton Tw1ns

5 PHR/1000 TB

Slngleton Twins babies

6 Stlliborn Singleton T",lns babies

7 END Singleton T",lns babies

8 Abort1on

No 9 TT l~nlsotlon

-

SAFE MOTHERHOOD STUDY PROBOLINGGO DISTRICT (A) MUNICIPALITY (B) AND PASURUAH DlsrRler (e)

AUGUST 1992 - JULY 1993

A B pre RISk post ::iurvey Pre Rlsk Pas t -Suivey Survey Scoring Screened Unscreened Survey Scoring Screened Unscreened

7948 7169 4473 1521 1425 1206 6~4 4~9 7879 7135 4453 1518 1414 1201 649 4S9

69 33 20 3 11 5 S 0 0 1 0 0 0 0 0 0

8017 7204 4493 1524 1436 1211 659 4,<J 7879 7135 4453 1518 1414 1201 649 45<j 138 66 40 6 22 10 10 0

0 3 0 0 0 0 0 0

7876 1011 4380 1461 1434 1]04 b," 4,ti 1146 6941 4340 1455 1412 1196 6"" 4,ij 130 61 40 6 22 8 10 0

0 3 0 0 0 0 0 0

24 26 15 11 1 0 0 0 304 1) (370 8) (342 5) (752 9) (69 7)

23 26 15 11 1 0 0 0 1 0 0 0 0 0 0 0

248 345 193 89 8 18 15 1 (30 9) (47 9) (42 9) (58 4) (5 6) (14 9) 119 1) (2 2)

237 336 193 89 1 16 15 1 11 9 0 0 1 2 0 0

141 193 113 63 2 7 5 1 133 188 113 63 2 5 '> 1

8 5 0 0 0 2 0 0

101 152 80 26 6 11 8 0 104 148 80 26 5 11 8 0

.3 4 0 0 1 0 0 0

59 81 86 15 3 2 (0 91) (l 11) (1 41) (1 11) (0 21) (0 21)

1291 990 1167 752 184 29 48 48 (16 21) (13 81) (26 11) (49 41) (12 91) (2 41) (1 31) (10 41)

~-

C Pre Post Survey Survey

6441 4153 I

6392 4724 S5 29 I

0 o I

6S02 4782 ,

6392 4724 110 ~B

0 0 I

6439 4105 6B4 4652

lOS 53 0 0

10 14 (1'>'> 3) (291 6)

9 14 1 0

105 110 I

(16 1) (23 0) !

96 105 9 5

63 77 58 72 5 5 I

42 33 38 33 4 0

40 13 (0 flI) (0 31

1583 1161 (21 51) (24 41

~--

PRE-SURVEY I AUGUST 1991-JUlY 1992, RISK SCORING AUGUST 1992-JULY 1993 POSJ-SUUV£¥ AUGUST 1992-APRIL 1993

APPENDIX 4

Table I: Perinatal Mortality by Antenatal Risk Score, Probolinggo, implementation: SensItivity, Specificity and Postive Predictive Value

Table 2: Maternal Mortality by Antenatal Risk Score, Probolinggo, implementation: Sensitivity, Specificity and Postive PredJctJve Value

, 11

Table 1

Perinatal Mortality by Antenatal Risk Score

Probolmggo, East Java, 1992 -1993

Pennatal Death

RIsk Score Yes No

HR & VHR 193 2,645

LR 170 5,930

Total 363 8,575 SensltJvlty" , 93> 363 • 53 ... SpeCIfICIty = 5 93C18 5~5 & 69 ... PPV = 193>2830 : 68 ...

Table 2

Maternal Mortality by Antenatal Risk Score

Total

2,838

6,100

8,938

Proboilnggo, East Java, 1992 -1993

Maternal Death

RIsk Score Yes No Total -

HR & VHR 17 2588 2605

LR 9 5561 5570

Total 26 8 149 8,175

Sensitivity. I ~ 26 • 65"" Specificity· 5 561 8 149. 68"" PPy • 1 ~"2 605 • 065""