AN INTEGRATED VILLAGE MATERNITY SERVICE TO IMPROVE REFERRAL PATTERNS IN A RURAL AREA IN WEST-JAVA

The Regionalization of Perinatal Care, an intervention study carried o ut in Tanjungsari, a subdistrict in rural West Java, aimed to develop a comprehensive maternal health program to improve maternal and perina tal health outcomes. The main inputs included training at all levels o f the health care system (informal and formal) and the establishment o f birthing homes in villages to make services more accessible. Special attention was given to referral, transportation, communication and ap propriate case management, A social marketing program was conducted to inform people of the accessible birthing homes for clean delivery, lo cated near the women, and with better transportation and communication s to referral facilities should complications arise. The study design was longitudinal, following all pregnant women from early pregnancy un til 42 days postpartum in an intervention and a comparison area. The p opulation was +/- 90 000 in the intervention area and 40 000 in the co mparison area. Inclusion criteria were all mother and infant units del ivered between June Ist, 1992 and May 31st, 1993. Analysis showed the following results: Most women sought antenatal care (> 95%). In Tanjun gsari, nearly 90% sought such care from professional providers as vers us 75% in the control area of Cisalak. Most women with bleeding or ble eding and edema during pregnancy sought professional assistance in bot h the study and control areas. However, fever for more than 3 days rec eived more attention in the study area versus control area (93 vs. 69% ). Greater than 85% of deliveries in both areas were conducted by TBAs . However, in the study area, nearly one-third of those with intrapart um complications (17%) delivered in a health facility compared to one- tenth in the control area. This meant a hospital delivery, primarily w ith assistance of a doctor or doctor/midwife combination. Overall refe rral rates by TBAs were low - 13% of women with complications in Tanju ngsari and 6% in Cisalak. More women with intrapartum complications we re referred in the study area than in the control, and more complied w hen referred. Women who suffered intrapartum complications were more l ikely to have a perinatal death. Perinatal deaths declined in Tanjungs ari, but not significantly. However, the trend over the period of the intervention shows an improvement in the deliveries managed by TBAs wi th more deaths resulting in the hands of professionals. Either women w ere arriving too late or the quality of care could not meet the needs. There was no change in the levels or place of perinatal deaths in Cis alak.