 So, it's my pleasure to be able to introduce our next speaker, which is Astri Nurdiana, and Astri is from Indonesia. She's a lecturer with the Midwifery Department in Singapore Bangsa Karawong University. She's also a private midwife, she has a private clinic where she provides maternal and child health care, including breastfeeding, consultation and preparation for safe and normal birth. Astri is very interested to develop, to improve health conditions in Indonesia through constantly delivering maternal health services, and she's passionate about midwifery education. She's also the head of the Indonesian Midwives Association Education Institution Branch. Her areas of research interest are in the things that are essential for midwives in Indonesia, understanding trends of maternal deaths in Indonesia, and developing a family planning counseling model based on a video. So, we're looking forward to hearing Astri's presentation on pregnancy care quality measurements in Indonesia, and I'll hand over to Astri now. Yeah, okay. Thank you, Robin, for the introduction. Good morning, everyone, and happy International Day of Midwives for all of us. It's such a pleasure and an honor to be here. This is my first time presenting on the virtual event like this. Yes, my name is Astri and my co-worker's name is Wai Wariah. Today I'm going to present our proposal about pregnancy care quality measurements in Indonesia. The background of this study is, as we know, that maternal mortality is still one of the serious issues in the world. In 2014, 27% of maternal mortality in the world caused by hemorrhage and undericosis. And other causes contributed to the maternal mortality are abortion, sepsis, emboli, and hypertension. The study found that most of the maternal mortality happened in low and middle income country, such as Indonesia, and we can see here the maternal mortality in Asian country. This figure shows that in 2014, Indonesia is the third highest maternal mortality in ASEAN after Laos and Myanmar. Based on the previous slide shows that the cause of maternal mortality are pre-pentable during the anti-natal visit. Now let's see the anti-natal care coverage in Indonesia. It became better from 2007 to 2012. The coverage on 2012 a lot more increased into almost 100% coverage. So most of the causes of maternal mortality can actually be prevented. Prevention can be done since pregnancy. Therefore, quality of pregnancy care can be the key to the success of reducing the maternal mortality rate. Now I'd like to show you the maternal death incidence in Karawang City. So actually this research will be conducted in Karawang City. But before that, I'd like to introduce what it is like. As we all know that Indonesia is an archipelago country which has many big islands and province. West Java is one of it. In West Java, there are several cities and there is the city called Karawang. Karawang was agricultural city, but now it turned into industrial city. The economic aspect grows so fast as well as education, architecture and business aspect. This condition makes Karawang become most popular city in West Java and attracts many migrants from outside the city and country. There are many culture and race in Karawang, but this improvement is not in line with the health improvement. Karawang contributes more to the maternal mortality rate in West Java. In 2013, Karawang is the second highest city with maternal death incidence in West Java. Now let's see the maternal mortality incidence in Karawang from 2007 to 2018. In the last three years, the maternal death incidence tend to decrease from 68 to 61 of 59. And last year it was 46 maternal death incidence in Karawang. It seems change a lot, but the maternal mortality are still happen for two to three deaths a month. This is the maternal death cause in Karawang. There are three major causes of maternal mortality in Karawang and it constantly caused by the same case every year. There are preeclampsia, hemorrhage and heart disease and it seems like preeclampsia dominate the causes. Best on the maternal death data in Karawang in 2015 to 2018 most of the maternal death happen to the mother with antenatal care more than four times along their pregnancy. So in Indonesia we have minimum standards of antenatal care of one time in the first semester, one time in the second semester and two times in the third semester. So the most maternal death happen to the mother with the good antenatal care frequency. A serious problem now is this is become serious problem because it's supposed to be more antenatal care or more visit, the more prevention could be conducted. So the hypothesis of this study that there are some non-adherence in carrying out antenatal care standards by the midwives. So the aim of the study is to identify the implementation of antenatal care carried out by midwives in Karawang city based on 10 T antenatal care standards. What are the 10 T standards? 10 T standards come from Indonesian terminology where all the letters begin from T but when it's translated to English actually it's not T anymore but I'll keep this 10 T on this proposal. Anyway the 10 T are head and weight measuring, blood pressure measuring, thunder's head measuring, TT immunization screening, FF supplementation, nutritional status assessment, laboratory testing, fatal presentation and fatal heart rate examination, case treatment and health education and I added two more variables based on the journal of red that waiting time and duration are two indicators of quality. Waiting time is the time when the patient come to the community health center until they get they are getting the service from the midwife and the duration is the length of the service provided by the midwife. A population of this study are 864 midwives in 50 community health center in Karawang after I counted it so I need 70 samples for a midwife. I counted it proportionally and I will do this in this research in 50 community health centers in Karawang. The study will be conducted in six months from May to November 2019 and to prevent the bias while doing the observation so the study will be used blind observation study. So the midwives will act naturally while they are providing the antenatal care. Who are the observers? The observers are the students midwives who are trained to observe and the data analyzing this quantitative research the validity and reliability of the questionnaire will be tested and the final questionnaire will be used for this research then the midwife characteristics also become the variables of the study and then the data will be analyzed descriptively. Okay I think that's all what I can present to you today. Welcome for every for remark and questions. Thank you. Thank you very much for that presentation Astrid. I'm sure there are many questions that people would like to ask so please use the facility to make questions. Anyone who might like to ask? I might start the ball rolling. I'm quite interested to know the number of births that would normally occur in the Karawong area. You've said there were 864 midwives in 50 health centers so what is the number of births in this region? In the in province so there are you must be very surprised with this number 937,276 births a year. Per year yeah that's a lot of birthing women for 864 women midwives to look after isn't it? Yeah because Indonesia is one of the most populous country in the world. Yes I understand yeah. So every every community health center there are around 20 to 30 births every month in most of the health centers yeah health centers if in a hospital so there are around more than 100 births every month. Every month or every day? Every month every month every day there are maybe there are around 10 every day or normal birth for normal birth. I was very interested in the graph that you had up showing the percentage of maternal deaths by numbers of visits and the the number of maternal deaths was higher in the women who had had the the minimum standard of antinatal care. Would you like to comment a little bit more on that? Yeah I think this is the same question like I showed that Fiona asked. Yes Fiona just got that question. Yeah this is one serious problem about the antinatal care provided by the midwife. The antinatal care is supposed to reduce the maternal mortality but I saw the reality in the community health center about the antinatal care that conducted by the midwife so there are 10 standards it's supposed to be there are 10 standards but some standards I saw some standards aren't conducted by the midwife or yeah skip or or like in the yeah some we have we have to examine the pregnant woman very carefully but this is one of the biggest problem we have in the community that our midwife's care need to be I mean they are have to be adherence to the surface that they are providing. So your the so your idea then is that the midwives are not doing all of those 10 required steps in their usual antinatal care at the moment that's your hunch that you're going to go out and and examine is that right? Yeah that's right that that is my purpose of this study so now we have a program here in Karawang that some of antinatal care conducted also by the OBG decided by the midwife. Right and Deb's asked you a question about do women mainly go to a qualified midwife or do they go to traditional birth tendons as well? Yeah for for now there are most of them go to the qualified midwives there are no more birth tendons in Karawang or in Indonesia we have less than maybe less than 10 years. And do the OBGYNs do they do the same 10T standards? Yes but the different between OBGYN midwives OBGYN they do ultrasound as well. So now in yeah in I don't know whether this is the same the same the same thing with another country or not so the the competence of ultrasounds just only can conduct it by the OBGYN. Yes and Michaela's asked a question about do women keep their their pregnancy records? Yes the women keep their pregnancy records on the book we called it maternal and child health book but again some of the some some of the patients sometimes they don't bring it to the health center or to when they when they went to when they are going for checking after the midwives sometimes they left their book at home so sometimes midwife missed the the records in that book. Can you tell us a little bit more about the the blind observations and and how they'll be done and what kind of training will be given to the student midwives to do this? Yes so the blind observation are going to conducting by the the first I trained the student midwives about a feeling of the questionnaire and what they are supposed to do with the checklist and then I I mean I sent all the students to the community health center by the purpose to learn about midwifery midwifery skills but beside that they have the test to do an observation when the midwife doing the examination to the pregnancy woman. So the the midwife doesn't know that they are being observed okay and after that they will they will fill the questionnaire and the checklist and then I will see the filled questionnaire and I yeah that's the research data. There's a question another question that's just come on from Sahiri. How do you treat with a mother's death? I mean is there a rule? Okay Sahiri you might want to just clarify what you're asking? Yeah yeah yeah I think I understand the next question. Okay I'll answer about that. So the maternal mortality I mean it's such a serious problem in Karawang. I mean why I chose Karawang as the place for my research now because there are many pilot projects conducting here from USAID or like many international international organization and the pilot project always succeeds and now we have many efforts to to give the solution to the maternal mortality in Karawang. We have many programs but when there is the maternal death in one health center the the midwife or the health practitioner must report it to the health office the local health office and then the local health health officer will come to the health center and we have also maternal audit maternal audit and also we usually do the interview to the family who attend the birth and also we do the interview to village midwife so there are three data that come from the local health center from the family and from the midwife who have delivered the baby at that time and then the data will be presented in the maternal death audit with the OBG as the speaker and at that time there is also the delegation from the profession organization midwives association. Is there answer to question? Sherry said thank you so I think you have managed to answer her question really well. Are there any more questions that anyone would like to ask Astrid? I really welcome everyone to join the project here I mean my city my city here really need the many inputs many innovation in yeah solution to decrease the maternal mortality and what would you want people to do to help? Yeah for everyone I think yeah the access to the knowledge is one more most the most important thing for the for the people the people the people need more knowledge more knowledge in the about the health about the risk of pregnancy yes we do we we do have the program called maternal maternity class but again it need more evaluation on it well it sounds like your process that you're going to be doing now is moving some way towards finding some some solutions to the high rates of maternal death through the provision of antinatal care so well done for that it's a good project yes thank you no more questions then all we all we do then is thank Astrid very very much for her really wonderful presentation on the quality pregnancy care in her area in Indonesia this was Astrid's first go doing an online presentation and I think she's done a tremendous job so well done Astrid.