Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine Health Policy

icy and Planning 2008;23:67–75

ß The Author 2007; all rights reserved. Advance Access publication 30 October 2007 doi:10.1093/heapol/czm036

Midwifery provision in two districts in

Indonesia: how well are rural areas served?
Krystyna Makowiecka,1* Endang Achadi,2 Yulia Izati2 and Carine Ronsmans1

Accepted 13 August 2007

Attention has focused recently on the importance of adequate and equitable

provision of health personnel to raise levels of skilled attendance at delivery and
thereby reduce maternal mortality. Indonesia has a village-based midwife
programme that was intended to increase the rate of professional delivery care
and redress the urban/rural imbalance in service provision by posting a trained
midwife in every village in the country. We present findings on the distribution
of midwifery provision in our study area: 10% of villages do not have a midwife
but a nurse as a midwifery provider; there is a deficit in midwife density in
remote villages compared with urban areas; those assigned to remote areas are
less experienced; midwives manage few births and this may compromise their
capacity to maintain professional skills; over 90% of non-hospital deliveries take
place in the woman’s (64%) or the midwife’s (28%) home; three-quarters of
midwives did not make regular use of the fee exemption scheme; midwives who
live in their assigned village spend more days per month on clinical work there.
We conclude that adequate provider density is an important factor in effective
health care and that efforts should be made to redress the imbalance in
provision, but that this can only contribute to reducing maternal mortality in the
context of a supportive professional environment and timely access to emergency
obstetric care.
Keywords Midwife, Indonesia, maternal health, workforce, workload, delivery, distribution,
density, equity

KEY MESSAGES

Most deliveries are managed by a single-handed midwife in a woman’s home where conditions may be basic and her
capacity to access emergency care limited.

There is a paucity of midwives in remote villages resulting in a more demanding and isolated professional environment
with a high turn-over of practitioners.

The low obstetric workload of midwives compromises their professional capacity through lack of skill maintenance.

A policy shift from home births to community-based facility births would enable midwives to offer a better service by
operating in teams, thus increasing their obstetric workload and thereby their exposure to complications, and by
facilitating access to emergency obstetric care.

1
Department of Epidemiology and Population Health, London School of
Hygiene and Tropical Medicine, London, UK.
2
Centre for Family Welfare, University of Indonesia, Depok, West Java,
Indonesia.
* Corresponding author. Department of Epidemiology and Population
Health, London School of Hygiene and Tropical Medicine, Keppel Street,
London, WC1E 7HT, UK. Tel: þ44 (0) 20 7927 2812.
E-mail: krystyna.makowiecka@lshtm.ac.uk
Introduction
The 2006 World Health Report proposes that density of health
care provision is key to achieving the fifth Millennium
Development Goal: reduction of maternal mortality by 75% by
2015 (WHO 2006). Over two-thirds of maternal deaths are a
direct result of obstetric complications (Ronsmans and Graham
2006), and most could be avoided with good quality skilled care

67
68 HEALTH POLICY AND PLANNING
at delivery (Graham et al. 2001; WHO/ICM/FIGO 2004;
Campbell and Graham 2006). High levels of skilled care can
only be achieved with adequate and equitable distribution of
health personnel (Anand and Baernighausen 2004; Campbell
and Graham 2006; Koblinsky et al. 2006) operating in a
well-functioning and supportive system with timely access to
emergency obstetric care. In this paper we focus on one aspect
of such care: the distribution of providers in relation to both
their density and their professional characteristics.
There exists a substantial wealth gradient and urban/rural
split in developing countries in both maternal mortality
(Graham and Bell 2004) and uptake of skilled attendance
(Gwatkin 2000; Hatt et al. 2006). Wealth tends to be
concentrated in urban areas and services are provided in the
places where demand is high and people are able to pay.
Globally, the proportion of services in towns and cities exceeds
the proportion of population living there and rural deficits are
substantial. For policy-makers to fill these gaps in provision,
local knowledge of health provider density and skills is needed,
as well as epidemiological and demographic profiles of the
community they serve (Lancet Editorial 2006), yet the 2006
World Health Report reveals a paucity of such information
(Anand and Baernighausen 2004; WHO 2006).
Indonesia has been identified as one of 57 countries with a
critical shortage of health personnel (WHO 2006), but on a
national level there is no shortage of midwives, largely a result of
the village-based midwife programme. This initiative, launched in
1989 (Government of Indonesia 1989), was unique as a national
effort to follow the World Health Organization’s (WHO) guidance
for safe motherhood. It sought to address high maternal
mortality, thought to be a result of a dearth of midwives and
under-use of services (World Bank 1994), particularly in rural
areas, by assigning a midwife to each village in the country and
thereby raising skilled attendance. Existing nurses were to be
trained in midwifery under an intensive 1-year programme, to
live in and work from a village birthing facility provided by the
community for which they had responsibility, and to operate as
multi-purpose providers, but with specific responsibility for
pregnancy, delivery and post-partum care (Government of
Indonesia 1989; Hull 1998; Geefhuysen 1999; Shiffman 2003).
Within 7 years, over 54 000 new midwives had been posted
(Ministry of Health 1997), virtually each village in the country
had its own assigned provider and the percentage of births in
rural areas managed by a midwife doubled, from 22.5% in 1990
(BPS et al. 1995) to 55% in 2003 (BPS and ORC Macro 2003).
Midwives received a monthly income for their routine public-
sector clinics and in addition were allowed to charge a fee for
delivery care. Families defined as ‘poor’ were entitled to free
delivery care and in these cases midwives were remunerated
through a fee exemption scheme.
The challenges to sustaining such a programme are sub-
stantial. Ever since near-universal coverage was achieved in the
mid-1990s, there have been problems of retention, especially in
remote areas (UNICEF 1997; Daly et al. 1998; World Bank 1999).
Indonesia experienced a major economic crisis in 1997 and
government expenditure on health and education declined
along with use of public health care services (Frankenberg
et al. 1999; Simms and Rowson 2003; Waters et al. 2003).
Furthermore, under the national decentralization plan
(Government of Indonesia 1999), financial responsibility for
the village-based midwife programme, traditionally the central
government’s, increasingly fell to the authority of districts,
which had variable capacity to pay.
In addition, the 1-year midwifery training programme was of
questionable quality, inadequate duration and, because of a
combination of the high number of midwives being trained,
low fertility and low use of facilities, many midwives had
virtually no experience of managing a delivery during their
training. Small-scale evaluations suggest that midwives who
qualified under this scheme did not have the skills or
knowledge needed to perform their midwifery duties effectively
(Depkes/POGI/IBI 1998; McDermott and Beck 1999; HMHB
2001; McDermott et al. 2001; Koblinsky 2003; Sadjimin 2003;
MSH 2004). This is of particular concern because although
village-based midwives were under the general formal super-
vision of the health centre, they were to manage normal
deliveries alone and may not have had the skills to recognize an
obstetric emergency and the need for referral. In 1996,
additional training needs arose when those working out of
reach of facilities were given formal authority to practice
independently and to perform a range of procedures, including
vacuum extraction and forceps delivery (Government of
Indonesia 1996). To address these needs, competence-based
in-service training courses, comprising classroom-based training
using models and supervised clinical training, were developed
by the newly formed National Clinical Training Network in the
management of normal delivery and life-saving skills. In 1996,
the 1-year pre-service training course was replaced by a 3-year
specialist programme open to high school graduates.
In this paper we examine the village-based midwife pro-
gramme by describing the provision of midwifery services in
two districts on Java Island. We examine the midwives’
professional characteristics and their place of work relative to
the population and area that they serve, and discuss the place
of workforce density in a strategy to reduce maternal mortality.
Methods
Study area
We conducted the study in Serang and Pandeglang districts in
Banten Province on Java, Indonesia. Serang City is the provincial
capital and is situated 100 km west of Jakarta, the national
capital. The district of Serang comprises 373 villages and a
population of 1.8 million. There are three hospitals (a large
Provincial tertiary hospital and two smaller private hospitals)
and 36 health centres. Its economy is based on medium-scale
manufacturing, tourism and small-scale fishing and agricultural
activity. It borders a large industrial development to the West and
rapid urbanization to the East. Pandeglang district comprises 335
villages and is characterized by small-scale farming, mountains
and forest, with some palm oil and tea plantations and coastal
tourism. It has a population of 1.1 million who are served by one
district hospital and 30 health centres.
Study population
The study population comprised all practitioners registered to
provide midwifery care in the two districts in July 2005,

irrespective of whether they held a contract with the District
Health Office (DHO), and those nurses who were assigned to
villages to offer maternal and child health care. We obtained a
list of these providers from the DHOs. Free and informed
consent of all respondents was obtained.
Data collection
We drew on four sources to describe midwifery provision in the
study area. First, all midwives and nurses with midwifery
responsibility listed by the DHO were invited to complete a
questionnaire in September 2005 on their professional char-
acteristics, including training, type of employment contract and
workload. Secondly, those who had been assigned responsibility
for one or more villages were asked to complete a questionnaire
on their clinical work in the villages. Thirdly, we drew on
National Statistical Office data for the size and population of
each village and for its classification as urban or rural. Finally,
field staff generated data on distances from a village to the
nearest public hospital within the study area using Geographic
Positioning Systems.
Definition of variables
Providers were characterized by their principal midwifery role:
village-based midwives (midwives who had been assigned
responsibility for midwifery provision in one or more villages);
health centre midwives (midwives who have administrative and
supervisory duties in the sub-district health centre and in
addition may have been assigned responsibility for villages);
nurses (who, in addition to their nursing duties, had been
assigned responsibility for village-based midwifery care);
private community midwives (whose principal midwifery role
was in the community and whose work was in the private
sector only); general hospital midwives (whose principal
midwifery role was in a public hospital); other hospital
midwives (whose principal role was in a military or private
hospital); and other midwives (whose principal role was in the
District Health Office or midwifery academy).
Providers were further characterized by their years of service,
the nature of their contract, whether or not they offered private
care, the nature of their pre- and in-service training and their
obstetric workload. We distinguished three types of contracts:
private; public with security of tenure and pension rights; and
public with 3-year rolling employment and no pension rights.
Pre-service training comprised a 1-year diploma course for
graduates of the nursing high school or a 3-year midwifery
diploma for graduates of any high school. We defined obstetric
workload as the median number of times providers attended
women at the time of delivery or in the immediate postpartum
period in the preceding 3 months. The deliveries attended
outside hospital were also broken down by place of delivery: the
woman’s home, the midwife’s home (in a small number of
cases this has been provided by the community to function as a
place of clinical work), a private community facility or a public
community facility (health centre or health post). In general,
the health centre has an administrative and supervisory
function and does not provide routine intrapartum care.
In Indonesia the village is the smallest unit of government
administration and all villages are defined by the National
Statistical Office as urban or rural. In this paper we extended
MIDWIFERY PROVISION IN INDONESIAN VILLAGES 69
this classification to include a ‘remote’ category. Remote
villages exist only in Pandeglang and were defined as those
that lay further than 33.3 km (the median distance of non-
urban villages in this District) from the nearest government
hospital in the study area. Although some villages in Serang are
further than 33.3 km from a government hospital, these are not
classified as remote because they lie close to neighbouring
suburban or industrial areas and are well served by transport
and service infrastructure.
Village-based and health centre midwives and nurses may be
assigned one or more villages of responsibility, possibly sharing
this assignment with another provider. The assigned provider
may or may not live in the village and other midwives who live
in the village may also offer delivery care. In order to examine
the intensity of midwifery provision, we described villages by
the resident midwife to population ratio and the number of
resident midwives per square kilometre. In these calculations
we excluded nurses because they do not have a license to
manage normal deliveries and have had no midwifery training.
We also describe villages in relation to the assigned provider
(generally a midwife but where no midwife is available, nurses
take on this responsibility): the number of other villages for
which she has responsibility; how long she has been assigned
to the village; how long she has been a midwife and her
principal role.
Data analysis
Data analysis was undertaken using Stata9 (http://www.stata.
com). We compared provider characteristics according to the
professional role of the provider, and the intensity and nature
of the assignment comparing urban, rural and remote villages.
Proportions were compared using the 2 test and medians and
provider per population rates using weighted Kruskal-Wallis
test of significance.
Results
Characteristics of midwifery providers
The DHO identified 753 midwives and nurses with a midwifery
role in the two districts in 2005. 737 (98%) agreed to participate
in the study. Of these, 464 (63%) worked in Serang and
273 (37%) in Pandeglang. Almost half (49%) were village-based
midwives, over a quarter (26%) health centre midwives
and 9% were nurses with no midwifery qualifications. Only
50 (7%) providers worked exclusively outside the public sector
(Figure 1).
Village-based midwives were less experienced than health
centre midwives (Table 1). Ninety-four per cent of village-based
midwives had worked for 15 years or less, compared with 67%
of health centre midwives (P < 0.001). Village-based midwives
were also more likely than health centre midwives to
have temporary contracts (46% vs. 3%; P < 0.001) (Table 1).
572 (79%) of the 724 respondents had a village assignment,
comprising all 361 village-based midwives, all 69 nurses and
three-quarters (74%) of the 193 health centre midwives
(P < 0.001) (Table 1).
Most (79%) midwives qualified under the 1-year diploma
course and were therefore nurse-midwives, but a larger
70 HEALTH POLICY AND PLANNING

proportion of private and hospital midwives than village-based
or health centre midwives had completed 3-year specialist
training. Of the public community providers, nearly all (94% of
village-based midwives and 95% of health centre midwives)
had completed some in-service training courses to improve their
capacity to recognize and manage complications, except for
nurses, only 17% of whom had received any such training.
400
49%
350
300
Number of providers
Obstetric workload and private care
Almost all (98%) village-based and (94%) health centre
midwives had assisted women around the time of delivery
over the preceding 3 months, while fewer than half the nurses
(46%) had done so (Table 1). Among those who had attended
women during labour, delivery or the immediate postpartum
period, the total number attended was very low, with a median
of 10 (IQR: 6–18) over 3 months. Nurses assisted fewest
deliveries (median: 3, IQR: 2–7) and hospital midwives the
most (median: 20, IQR: 9–50) (P < 0.001) (Figure 2).
The number of non-hospital deliveries that took place in the
woman’s home, the midwife’s home and in a health centre was
calculated for each midwife based on data from the midwives’

250 questionnaire on their attendance at deliveries in the preceding

26% 3 months. Just 7% of non-hospital deliveries took place in a
200
community facility and most took place in the woman’s (64%)
150 or the midwife’s (28%) home (Figure 3). Three-quarters (75%)
of the respondents, regardless of the provider type, charged
100
9% a private tariff for all the deliveries they had managed outside
7%
50
3% 4% a hospital over the preceding 3 months (data not shown).
2%
0
Village Health Nurse Private Public Other Other
midwife centre community hospital hospital
Coverage of midwifery care in villages
midwife midwife midwife midwife Village characteristics
Figure 1 Distribution of midwifery providers in Serang and Of the 708 villages in the two districts, 55 were in urban Serang
Pandeglang districts, showing number and percentage of providers and 318 in rural Serang, and 23, 156 and 156 in urban, rural
according to principal midwifery role and remote Pandeglang, respectively. The median population

Table 1 Employment and training characteristics of midwifery providers in Serang and Pandeglang districts, Banten Province, Indonesia,
September 2005

Private
Village Health centre community Hospital
a
midwife midwife Nurse midwife midwife Total P for test of
n ¼ 361 (%) n ¼ 193 (%) n ¼ 69 (%) n ¼ 25 (%) n ¼ 76 (%) n ¼ 724 (%) significance
Employment and workload
Years of service
0–5 16 (4%) 10 (5%) 30 (43%) 6 (24%) 20 (26%) 82 (11%) 2: P < 0.001
6–15 326 (90%) 119 (62%) 27 (39%) 15 (60%) 38 (50%) 525 (73%)
>15 19 (5%) 64 (33%) 12 (17%) 4 (16%) 18 (24%) 117 (16%)

Contract type
Temporary 166 (46%) 5 (3%) 40 (58%) 0 (0%) 14 (18%) 225 (31%) 2: P < 0.001
Permanent 195 (54%) 188 (97%) 29 (42%) 0 (0%) 46 (61%) 458 (63%)
Private 0 (0%) 0 (0%) 0 (0%) 25 (100%) 16 (21%) 41 (6%)
Village assignmentb 361 (100%) 142 (74%) 69 (100%) n.a. n.a. 572 (79%) 2: P < 0.001
Any birth attendance 355 (98%) 182 (94%) 32 (46%) 23 (92%) 66 (87%) 658 (91%) 2: P < 0.001
in last 3 months

Midwifery training
1-year pre-service training 340 (94%) 168 (87%) n.a. 16 (64%) 50 (66%) 574 (79%) 2: P < 0.001
c
3-year pre-service training 20 (6%) 25 (13%) n.a. 9 (36%) 26 (34%) 80 (12%)
Any in-service training 339 (94%) 184 (95%) 12 (17%) 17 (68%) 58 (76%) 610 (84%) 2: P < 0.001
d
Life-saving skills training 226 (76%) 118 (72%) 0 (0%) 4 (22%) 17 (26%) 365 (59%) 2: P < 0.001
Training in normal delivery 66 (18%) 51 (26%) 2 (3%) 3 (12%) 28 (37%) 150 (21%) 2: P < 0.001
a
Nurse with midwifery responsibility.
b
Personal data on one assigned midwife missing.
c
One midwife with other training.
d
Basic non-clinical training lasting over 10 days.
 MIDWIFERY PROVISION IN INDONESIAN VILLAGES 71

per village was 3500 and the median village area 4 km2. Urban (1.9 per 10 000) and nearly four times as high as the resident
villages are smaller and more highly populated than rural midwife to population ratio in rural Serang (1.3 per 10 000) or
villages (Table 2). remote Pandeglang (1.3 per 10 000) (Table 2). Midwife density
measured by square kilometre for each resident midwife is over
Resident midwives 30 times higher in urban (0.77 km2 per resident midwife) than
Over half the urban villages had three or more resident in remote villages (25 km2 per resident midwife).
midwives, compared with 3% or less in rural and remote
villages (Figure 4). Of the 626 midwives who were residents of Assigned providers
Serang and Pandeglang, 310 (50%) lived in urban areas, The 708 villages were covered by 572 providers with a village
resulting in 4.8 resident midwives per 10 000 urban population. assignment, comprising 503 midwives and 69 nurses. Most
This is two and a half times as high as in rural Pandeglang (61%) villages had an assigned provider who worked solely in
that village, while one-third (29%) shared their provider with
one other village and 10% shared with two or more other
250

villages (Table 2). These divided assignments were most

common in remote villages: nearly all (94%) villages in urban
Median number of times obstetric help given

areas had their own assigned provider, while less than a quarter
200

of villages in remote Pandeglang (24%) did so. In only a third

(29%) of villages overall was the assigned provider resident,
150

and this was the case in a higher proportion of urban villages

(44%) than outside the urban areas (24% in rural Serang, 29%
100

in rural Pandeglang and 31% in remote Pandeglang).

Assigned providers spent an average of 10 days per month
doing village-based clinical work. In remote Pandeglang they
50

spent 7 days (IQR: 3–19) per month, significantly fewer

(P < 0.001) than the 20 days (IQR: 10–25) spent in urban
0

areas (Table 2). An assigned provider who is resident in

Village Health centre Nurse* Private community Hospital
*nurse with midwifery responsibility
her village of responsibility spends a median of 20 days
Role of midwife (IQR: 12–26) on clinical work there, irrespective of the location
of the village (P ¼ 0.2). In contrast, assigned midwives who
Figure 2 Box plot showing median number of deliveries assisted by are not resident spend less than half the number of days on
midwifery providers registered in Serang and Pandeglang districts over
3 months, by principal midwifery role village-based clinical work and this differs significantly by
location (P > 0.001) (Table 2). Midwives had had responsibility
for their village for an average 4.7 years: 6 years in urban areas,
6000
compared with 3 in remote villages (P < 0.001). Villages in
urban areas were more likely to be assigned a health centre
midwife and nurses were particularly highly represented in
64%
rural Pandeglang (P < 0.001). Midwives had had their village
5000 assignment for a median of 6 years (IQR: 3.5–8) in urban areas,
Hospital midwife and only 3 years (IQR: 0.8–6) in remote Pandeglang.
The unequal deployment of providers in urban, rural and
Private community midwife remote villages resulted in a considerable range in the
4000
population and area to be covered by the assigned provider.
Nurse The median population covered by providers assigned to urban
Number of deliveries

and remote villages (6800 and 6700, respectively) was

3000 Health centre midwife significantly higher than those working in both rural Serang
(4700) and rural Pandeglang (3500). The median area of
28%
Village midwife responsibility of an assigned provider in remote Pandeglang
was over six times greater (18 km2) than in urban villages
2000 (2.7 km2). Assigned providers in remote Pandeglang managed a
significantly larger number of deliveries than those working in
other areas (P < 0.0001) (Table 2). Providers assigned to remote
villages managed a median of 14 deliveries over 3 months
1000
(IQR: 8–28), significantly more than those assigned to other
5% villages [urban 10.5 (IQR: 6–36); Serang rural 9 (IQR: 6–20),
2%
Pandeglang rural 10 (IQR: 6–24)].
0
Private home Midwife's home Public community Private maternity
facility clinic
Discussion
Figure 3 Non-hospital deliveries assisted by midwifery providers in
Serang and Pandeglang districts over 3 months, showing number and It was the vision of the village-based midwife programme that
percentage by place of delivery and role of provider each village in the country would have an assigned midwife
72 HEALTH POLICY AND PLANNING

Table 2 Characteristics of midwifery provision in urban, rural and remote villages in Serang and Pandeglang, Banten Province, Indonesia,
September 2005

Pandeglang Pandeglang Serang and

Urbana Serang rural rural remote Pandeglang
78 villages 318 villages 156 villages 156 villages 708 villages Test and P value
Village characteristics
Median village population in thousands (IQR) 6.5 (4.4-10.3) 3.9 (3-5) 2.6 (2-3.5) 2.8 (2.1-3.7) 3.5 (2.5-4.7) K-Wallis: P < 0.001
2 b
Median village area (in km ) 2.7 (2-3.9) 4.1 (2.9-5.7) 2.7 (2-3.7) 7.3 (4.6-15.5) 4 (2.5-6) K-Wallis: P < 0.001
c
Resident midwives
Resident midwife per 10 000 population 4.8 1.3 1.9 1.3 2.2 K-Wallis: P < 0.001
Km2 per resident midwife 0.77 10 5 25 0.2 K-Wallis: P < 0.001

Assigned provider
Number of villages for which assigned provider has responsibility
1 village 73 (94%) 226 (71%) 98 (63%) 37 (24%) 434 (61%) 2: P < 0.001
2 villages 5 (6%) 89 (28%) 53 (34%) 57 (37%) 204 (29%)
>3 villages 0 (0%) 3 (1%) 5 (3%) 62 (40%) 70 (10%)
Villages in which the assigned 34 (44%) 75 (24%) 46 (29%) 48 (31%) 203 (29%) 2: P < 0.001
provider is resident
Median number of days/month spent on clinical work in village (IQR)
Overall 20 (10-25) 12 (6-20) 8 (4-16) 7 (3-19) 10 (5-20) K-Wallis: P < 0.001
Resident 25 (20-26) 22 (12-30) 20 (14-25) 20.5 (10-25) 20 (12-26) K-Wallis: P ¼ 0.2
Non-resident 12 (8-20) 10 (6-16) 6 (4-10.5) 4 (2-8) 8 (4-15) K-Wallis: P < 0.001
Median number of years assigned to village (IQR) 6 (3.5-8) 4.8 (2.6-8) 4 (2-7) 3 (0.8-6) 4.7 (2-7.8) K-Wallis: P < 0.001
Role of assigned midwife
Village-based midwife 47 (60%) 225 (71%) 95 (61%) 93 (60%) 460 (65%) 2: P < 0.001
Health centre midwife 30 (39%) 64 (20%) 29 (19%) 54 (35%) 177 (25%)
d
Nurse 1 (1%) 28 (9%) 32 (21%) 9 (6%) 70 (10%)
Median population of responsibility in 6.8 (4.8-10.3) 4.8 (3.3-6.9) 3.5 (2.3-4.9) 6.7 (4.4-9.4) 4.9 (3.4-7.5) K-Wallis: P < 0.001
thousands (IQR)
Median area of responsibility in km2 (IQR)e 2.7 (2-4.1) 5 (3.3-8.2) 3.7 (2.3-5.5) 18 (8-47.9) 4.9 (3.1-9.3) K-Wallis: P < 0.001
Median number of non-hospital 10.5 (6-38) 9 (6-20) 10 (6-24) 14 (8-28) 10 (6-17) K-Wallis: P < 0.001
deliveries over 3 months (IQR)
a
Includes both Serang (55 urban villages) and Pandeglang (23 urban villages).
b
Data missing for 4 villages in rural Serang.
c
These figures exclude nurses with midwifery responsibility.
d
Nurse with midwifery responsibility.
e
Data missing for 4 villages in rural Serang.

who would live in and be part of the community she serves.
Considerable efforts were made to bring midwifery care to the
villages and there have been achievements in terms of midwife
to population density. Indeed, the figure of 2.2 midwives per
10 000 population in the two districts is broadly consistent with
the national midwife to population density of 2.0 per 10 000
(WHO 2006). However, figures that describe national coverage
mask local variation. The distribution of midwives in the study
districts reflects global trends (WHO 2006), with inequitably
distributed provision and remote villages in particular being
underserved compared with urban areas. This translates into
considerable advantages to urban residents. In contrast to rural
villages, urban areas have a more stable and experienced
workforce and are more likely to have resident midwives. In
addition, a larger proportion of assigned providers are resident,
can focus their professional attention on one village only and
therefore spend more days per month on clinical work there
and be a better-known figure in the community. In remote
villages the area of responsibility per assigned provider is larger
so the midwife is less likely to be a familiar figure. Transport
infrastructure is also less well developed, affecting the mid-
wife’s accessibility, her ability to reach a woman in labour and
her capacity to refer her to hospital should there be an obstetric
emergency (Thaddeus and Maine 1994). A tenth of our villages
have a nurse as an assigned provider because there is no
midwife available, and only one of these villages is in an urban
area. The nurses’ role is principally organizational (they are
licensed to manage deliveries only in emergencies), but in
reality they do offer delivery assistance without midwifery
qualifications, and in only few cases with in-service training.
Midwives are attracted to urban areas because they can
generate viable and sustainable clinical practices. Most,
irrespective of their contract status or place of work, offer
private services outside their government working hours,

70
60
% villages by number of resident midwives
50
40
30
20
10
0
Urban Serang Pandeglang
rural rural
Figure 4 Proportion of villages in Serang and Pandeglang districts with
no resident midwife, one or two resident midwives and three or more
resident midwives, by urban, rural and remote area
under a formal arrangement designed to enable public sector
providers to supplement their government pay. Midwives in
remote areas manage more deliveries than others: the provider
to population density is lower and there is limited competition
for their skills. However, notwithstanding the higher workload,
income remains lower in remote areas since the professional
fees reflect the population’s ability to pay (Center for Health
Research 2001). Remote postings may not have the capacity to
provide an adequate income for midwives and therefore may be
unsustainable without subsidy. The Ministry of Health has
adopted strategies to retain midwives in remote areas: financial
incentives in the form of an income supplement and a
guarantee of renewal of the rolling contract. However, these
incentives may be insufficient. The extra income earned from
private work with a wealthier population may exceed that
gained through government subsidy, and a renewal of a rolling
contract is not valued as highly as a tenured contract with
security of employment until retirement and a pension for life.
In addition, working in remote areas carries with it professional
isolation, greater pressure from a more traditional community
and less opportunity for career development.
As a consequence of the village-based midwife programme,
Indonesia has a midwife to population density of 2.0 per 10 000,
a figure similar to neighbouring Malaysia and Sri Lanka, both
countries which have achieved near universal skilled attendance,
with midwife densities of 3.4 and 1.6 per 10 000, respectively
(WHO 2006). However, midwives do not work in isolation, and in
order to save lives, they depend on a supportive environment and
access to a referral facility. Indonesia has a workforce density of
doctors, nurses and midwives of 9.5 per 10 000, while that of both
Sri Lanka and Malaysia is over twice this size (22.9/10 000 and
23.9/10 000, respectively). Indonesia’s health centres are poorly
equipped and poorly stocked (Setiarini 2003a,b), and while
the increased pool of midwives may have increased skilled
attendance, it has not yet been shown to have increased access to
emergency obstetric care, particularly for the poor (Ronsmans
2001; Hatt, in press).
MIDWIFERY PROVISION IN INDONESIAN VILLAGES 73
0 midwives resident In our study, the distribution of midwives in urban, rural
1 or 2 midwives resident and remote areas no doubt contributes to a substantial
3+ midwives resident differential in the uptake of skilled attendance. A recent
population-based survey in the two study districts suggests
that 33% of deliveries took place with a skilled attendant,
62% in urban areas, and 24% and 19% in rural and remote
areas, respectively (unpublished data). It is noteworthy that in
urban areas, where the density of midwives is 4.8 per 10 000
population, where assigned midwives spend more time than in
other areas on village-based clinical work, and where other
physical barriers such as transport are unimportant, skilled
attendance is still low, suggesting that supply alone is not the
problem.
Women who deliver with a traditional attendant may have a
strong attachment to birth traditions and would call a midwife
Pandeglang Total only in the event of an emergency. While demand for
remote
professional birth attendance may be stimulated though
public health messages, the financial barriers to using a
midwife are acute, particularly among the deprived populations.
The fee exemption scheme for the poor introduced in 1997 and
revised in 2005 represents a positive step; the low uptake in our
study may be because midwives were hesitant to use a system
that had recently been altered. Even though awareness of the
programme should be raised among service users and profes-
sionals alike, a targeted fee exemption scheme may not be
enough to render services accessible, since all countries that
have reduced their maternal mortality ratio have done so in the
context of free care (Koblinsky et al. 1999).
Midwives attend a median of 40 births per year. There is no
internationally agreed minimum number of deliveries that a
midwife should perform to maintain her midwifery skills, but
Scotland and Bullough (2004) recommend an optimal annual
workload for obstetricians of between 100 and 125 normal
deliveries. If the same recommendation is applied to Indonesian
midwives, their delivery volume falls well below optimal levels,
and their capacity to manage complications and recognize the
need for referral may be compromised because they come
across these situations so infrequently.
Most health centres in Indonesia have an administrative and
supervisory role, and few offer routine intrapartum care (Hatt,
in press). When the village-based midwife programme was
conceived, clinical care, including delivery care, was to take
place in a village-based birthing facility to be provided by the
community as a home and work base for the assigned midwife.
The facilities were of variable quality and in many cases were
not used (Hull 1998). The current system of community-based
midwifery provision effectively promotes home-based care. Our
results indicate that almost two-thirds (64%) of non-hospital
deliveries managed by midwives (estimated to be 96% of
all professionally managed deliveries in the study area—
unpublished data) took place in the woman’s home. In such
circumstances, midwives work alone and with one woman at a
time, and the extent to which they can increase their coverage
and gain sufficient experience to maintain skills is uncertain
(Koblinsky et al. 2006). In addition, conditions of home-births
can be basic (Chowdhury et al. 2006), and intra-partum care
less effective in terms of a midwife’s capacity to cope with
emergencies and less efficient than facility-based deliveries in
terms of the midwife’s time. An additional 28% of non-hospital
74 HEALTH POLICY AND PLANNING
deliveries managed by midwives took place in the midwife’s
home, where conditions may be better but the midwife remains
a single-handed provider. Globally, midwives working in health
facilities with an active role in intra-partum care assist more
deliveries because they can give care to more than one woman
in a given period and because they work in teams (Koblinsy
et al. 2006). The WHO proposes that such an approach enables a
midwife to manage 175 births per year (WHO 2005). A policy
shift from home to facility births may help establish a more
supportive working environment for midwives, may be more
efficient and effective in terms of the care that women receive
and, in terms of the retention of midwives in remote areas, may
be more sustainable. Data from Bangladesh indicate that such a
shift is possible even in settings with strong attachment to
home births (Chowdhury et al. 2006), and such a strategy may
be more efficient, effective and sustainable in reaching out to
women.
The Indonesian government has made great strides in
extending midwifery coverage to rural villages. Provision has
increased in all areas and skilled attendance rates have
followed. Notwithstanding a commitment to reducing maternal
mortality and attempts to introduce universal midwifery
coverage and fee exemption for the poor, it seems that the
primary beneficiaries have been the urban populations.
Midwifery services are least developed among the most
vulnerable women—those who live in remote areas.
We have examined the village-based midwife programme 16
years after its launch. The government’s vision of village-based
provision with qualified midwives living as part of the
community they serve has not been realised and today less
than 30% of providers live in the village to which they were
assigned. Redressing inequity in the distribution of midwives is
an important move towards improving maternal health services
for women in these areas, but it must be undertaken in the
context of other necessary elements of effective provision:
an accessible and affordable service comprising well-skilled
midwives operating in a supportive environment, with access to
emergency care. This would represent an important step
towards achieving the fifth Millennium Development Goal.
Acknowledgements
We thank our colleagues in the District Health Offices for their
support and cooperation: in the DHO Serang, Dr H Sulchi Aziz,
Dr Sri Nurhayati, Bd Euis Wangsih, and in the DHO
Pandeglang, Dr Gatot Supriadi, Dr Susi Badrayanti, Bd Oom
Rochmulyati. From the Ministry of Health, Jakarta, we thank
Dr Sri Hermiyanti and Dr Lukman HL. For their contribution to
the efficient running of the research, we thank Dr Anhari
Achadi, Reni Setiawaty, Nathya S Yahya, Sujoko Bayuaji, Eko
Setyo Pambudi, and Elang Rusdi.
This work was undertaken as part of an international
research programme, IMMPACT (Initiative for Maternal
Mortality Programme Assessment), funded by the Bill &
Melinda Gates Foundation, the UK Department for
International Development, the European Commission and
USAID (see http://www.abdn.ac.uk/immpact). The funders
have no responsibility for the information provided or views
expressed in this paper. The views expressed herein are solely
those of the authors.
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