Effectiveness of Advanced Midwifery Training on Midwives towards the Decrease of Maternal Mortality

  Last Update : Jumat, 28 September 2018

Effectiveness of Advanced Midwifery Training on Midwives towards the Decrease of Maternal Mortality

(Training carried out by Dr. Moch. Soewandhie General Hospital Surabaya)


Arif Setiawan* , Djazuly Chalidyanto**
* Departement of  Administration and Public Policy, Airlangga University, Surabaya

** Lecturer on Departement of Administration and Public Policy, Airlangga University, Surabaya



Arif Setiawan

Departement of  Administration and Public Policy, Airlangga University, Surabaya

Street of Dr. Ir. H. Soekarno, Mulyorejo, Surabaya, Indonesia. 60115





Background. The maternal mortality rate in Indonesia is still high. According to the Indonesian Demographic and Health Survey 2015, the maternal mortality rate was 305 deaths in every 100,000 births. This figure was still above the standard Millennium Development Goals (MDGs) which targeted the maximum maternal mortality rate 110 deaths per 100,000 births. Midwives are one of the health workers who have a role in reducing maternal and infant mortality. In addition to facilities, midwives knowledge about maternal health and children especially for childbirth cases has a major role in controlling maternal mortality. Therefore, further midwifery training related to preeclampsia detection and post-natal bleeding treatment needs to be conducted with the aim of reducing maternal birth rates. Objectives. The purpose of this study was to determine the effectiveness of advanced midwifery training in reducing maternal mortality. Methods. Training was given by Obstetrician Team from dr. Moch Soewandhie Hospital to midwives in 10 districts in Surabaya City. The method used consisted of training, discussion and demonstration. This study applied descriptive study using secondary birth data and maternal mortality rates. Results. The results of ongoing training conducted in 2016 and 2017 indicated reduction in maternal mortality in Surabaya. MMR in 10 districts in 2015 was 113.7 per 100,000 births and this figure was still above the MDGs standard. After MMR training conducted in 10 districts in 2016 the rate was 81.8 per 100,000 births while in 2017 the rate was 66.5 per 100,000 births. This figure reached the target of the MDGs.


Keywords: Maternal Mortality Rate, Midwife, Midwifery Training




Health problems in Indonesia require special concern from various parties. There are several indicators that can be used in assessing public health. One of them is through maternal mortality (MMR). MMR values ​​determine health status, and success of maternal and child health (MCH) services in the region. MMR according to the World Health Organization (WHO) is death during pregnancy up to a period of 42 days after the end of pregnancy, due to all causes related to or aggravated by pregnancy or treatment, but not caused by an accident or injury.


Maternal Mortality Rate in Indonesia is still high. In 2012 MMR in Indonesia was 359 deaths in 100,000 births, while in 2015 was 305 deaths in 100,000 births. Even though there has been a decline, this figure was still far above the Millennium Development Goals (MDGs) target which targeted 102 deaths in 100,000 births. The high MMR was caused by four too points (too old or too young for being pregnant, too many children, too close birth distance) and 3 late points (late to make decisions, late to the health service, late to get adequate help) (MOH, 2010). Whereas based on the kind of problem, the most common causes of maternal death are maternal bleeding, high blood pressure during pregnancy (eclampsia), infection, congestion and complications of miscarriage.


Midwives are the first health workers that provide childbirth assistance and have a major role in controlling maternal mortality. The roles of the midwife during midwifery care through consultation and referral during the period of labor with certain complications by involving clients and families, including: a. Examining the complication and emergency conditions of the mother and childbirth which require consultation and referral. b. Determining the diagnosis, prognosis and priority. c. Providing first aid to cases that require referral. d. Referring clients for further intervention needs to authorized health service personnel/ institutions. e. Recording and reporting and documenting events and interventions (Maramis, WF 2006). Therefore the knowledge and expertise of midwives is important in reducing MMR.


One way to increase midwife's knowledge is to conduct periodic counseling to midwives concerning pregnancy and maternal birth. Dr. Soewandhie Hospital, in collaboration with the Surabaya City Health Office conducted training for Midwives regarding Antenatal Care based on Postpartum Hemorrhagic Bleeding in which the training emphasized early detection of preeclampsia and postpartum hemorrhagic treatment which are the biggest cause of maternal mortality.

The study was conducted in 2016 and 2017, in the City of Surabaya. This study applied comparative non-experimental descriptive study with cross sectional approach. The population in this study consisted of entire midwives of the Health Centers and private practice in the North, Central and parts of East Surabaya.



Dr. Soewandhie is a type B hospital which is also a teaching hospital. The hospital has vision as a preferred and superior hospital in providing services and education in the city of Surabaya and a mission of providing professional health services, carrying out education, research in the field of quality health, and forming competent, well-mannered, integrity human hospitals, and building harmonious partnerships. With these vision and mission, Dr. Soewandhie Hospital felt compelled to conduct training for midwives in reducing maternal mortality in the Surabaya area.

In 2016 to 2017 the obstetric and gynecological specialists from Dr. Soewandhie Hospital in collaboration with the Surabaya City Health Office conducted training for midwives at the Health Centers and private practice in the North Surabaya area (Pabean, Krembangan, Semampir, Kenjeran and Bulak districts), Central Surabaya (Genteng, Tegalsari, Bubutan and simokerto Districts) and East Surabaya (Tambak Sari District).


Based on previous observations, it was determined that the training was conducted regarding Antenatal Care Management (ANC) based on Prevention of Postpartum Hemorrhagic Prevention in which the training was more emphasizing early detection of preeclampsia in pregnant women and Management of Postpartum Bleeding. This was chosen since it was one of the highest causes of maternal death. After the training, midwives who had been trained could do consultation using WhatsApp group whose members were consisted of trained midwives, obstetric and gynecology doctors from both Dr. Soewandhie Hospital and Surabaya City Health Office. Consultation could be done at the beginning of the ANC so that easy detection of abnormalities in the pregnancy could be found. In this forum, besides the disease problem itself, the member also discussed other constraints including financial problems that the health department could also provide the backup through Jampersal funds managed by Health Office. In addition, a maternal perinatal auditing is also performed in case of maternal death. This was done not to punishing or judging but to find out the cause of maternal death. Searching was done from the beginning of pregnancy until maternal death occurred so that the member could find out which part of the pregnancy process could prevent maternal death.


The training was aimed at the midwives because of its role as first medical personnel in handling of births, hence the knowledge of midwives greatly influenced the care that would be obtained by pregnant women. This was in line with the causes of maternal death that is 4 toos and 3 lates points aforementioned above, this training aimed to break the cause of being late which are late in making decisions, late to the health service and late to get adequate help. It was expected that midwives could provide adequate assistance to the childbirth so that it could extend the life expectancy of the mother. The number births and the maternal mortality rate can be seen in table 1.

Table 1. List of deaths and births in districts that received training in 2015, 2016 and 2017.










































































Tambak Sari















113,7 per 100.000 birth

81.8 per 100.000 birth

66.5 per 100.000 births


Based on Table 1, it can be seen that after the training program for midwives was implemented, there was a decrease in maternal mortality. This decrease was caused by the midwife already had the knowledge what to do if there were preclampsia cases in pregnancy and also in handling postpartum bleeding cases. It is in line with previous studies that stated Childbirth Care Training had a significant relationship with the knowledge of midwifery delivery assistance and with midwifery delivery assistance skills. Childbirth Care Training is able to increase the knowledge and skills of midwives for delivery assistance (Intan Sari ISBN 978-602-50798-0-1). With the increasing knowledge of midwives, the skills of midwives also increase, thereby increasing maternal life expectancy.


Figure 1. Graph of Maternal Mortality Rate in 10 districts conducted in 2015 and 2016

Figure 1 shows a graph of the reduction in MMR, in 2015 MMR was 113.7, which meant not in accordance with the standards set by the MDGs, namely 110. After regular training in 10 districts, there was a significant decrease until 2017 with MMR amounted 66.5. This decrease showed that the training carried out was effective in reducing the MMR. This was in line with previous studies which stated that Intensive Community Empowerment namely mapping strategy, intensive counseling, and empowerment of traditional birth attendants was a strategic program in reducing MMR (Rogo Sukmo, 2014). However, in this training, Dr. Soewandhie Hospital conducted training for midwives, unlike what was carried out by Rogo Sukmo who conducted training for traditional birth attendants, since there were no traditional birth attendants in the city of Surabaya. Another study that was also supportive was conducted by Endang Sulastri (2009) which stated that there is a change in motivation, attitude and skills in midwives after getting training. These changes in motivation, attitudes and skills made midwives better at providing services to pregnant and childbirth women. Good service, good skills and increased knowledge produce adequate help services at birth, therefore the mothers can give birth safely.



The Midwife Training Program carried out by the Dr. Soewandhie Hospital Team to midwives in 10 districts in Surabaya was effective in reducing maternal mortality. This was due to the selection of topics that were deemed appropriate to the factors causing maternal death, appropriate training in increasing the knowledge and skills of the midwives so that they can provide adequate birth assistance. Therefore it is advised to expand training coverage, not only to 10 districts but to be carried out in all districts in order to reduce maternal mortality and be able to achieve MDG standards regarding maternal mortality standards.



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