Presence of doctors and obstetrician/gynecologists for patients with maternal complications in hospitals in six provinces of Indonesia

To describe doctors’ and specialist physicians’ availability to manage obstetric complications in hospitals in six provinces of Indonesia.

prolonged labor, and complications of unsafe abortion. 4 Most childbirths in Indonesia are attended by a skilled birth attendant (83%), and the majority of these (63%) occur in a health facility. 5 Nevertheless, maternal mortality ratio estimates vary geographically-from 222 in Java-Bali to 430 in Sulawesi-and highlight disparities in terms of infrastructure and access to basic health services between provinces. 6 Issues around the number and maldistribution of healthcare staff as well as absence of staff and limited ability of the government to monitor the private sector are potentially contributing to Indonesia's continuing high maternal mortality. 1,7,8 Healthcare providers play a critical role in health service delivery but also in the economy more broadly. On the supply side of health services, the slow production, limited availability, and uneven distribution of the health workforce-especially doctors and specialist physicians-are challenges for Indonesia. 9 The World Health Organization (WHO), UNICEF, and UNFPA identified a package of services, known as emergency obstetric care (EmOC) that should be offered in all hospitals and health facilities to address the main causes of maternal death. 10 Comprehensive emergency obstetric care entails EmOC in addition to having the following: an emergency room doctor on call, 24-hour operating room and surgical team on standby, 24-hour blood bank services, and defined response times of 10 minutes for emergency room, 30 minutes for delivery room, and 1 hour for blood banks. 1,4 In Indonesia, general and specialist public hospitals are funded to provide comprehensive emergency obstetric and neonatal care (CEmONC or PONEK-Pelayanan Obstetrik dan Neonatal Emergensi Komprehensif). However, while women may have access to a CEmONC hospital, healthcare providers (both general doctors and specialist physicians, midwives, or nurses) must be available who can manage the presenting condition. Despite increases in the recent supply of doctors and specialists in Indonesia, there are substantial staffing gaps that affect the availability of a provider to manage complications 24/7. 9 In 2012, the Ministry of Health (MOH) estimated that-based on unfilled positions-an additional 118 788 healthcare providers were needed at hospitals before minimum staffing levels could be met across Indonesia. 9 This included an additional 87 874 nurses, 15 311 midwives, 3309 general doctors, 1382 pediatricians, 1287 obstetrician/gynecologists (ob/gyns), and 1295 internal medicine specialists.
While the absolute number of specialists and midwives has increased since 2005, in the case of specialists, this has barely kept pace with the population growth to date. More recently, there has been a rapid increase in student admissions to private and public schools for health professionals (doctors, specialists, midwives, and nurses). However, despite larger numbers of graduates, there is still a shortage of healthcare providers at hospitals and health centers (puskesmas). One study in 15 districts in Indonesia found that the provider density (number of doctors, nurses, and midwives per 1000 population) was low by international standards-11 out of 15 districts had provider densities less than 1.0, 11 far lower than the then WHO recommended standards of 2.3 healthcare providers (doctors, nurses, and midwives) per 1000 population. 12 Looking to the future, the current annual increase in the number of doctors seems unlikely to meet the government's 2019 target of one doctor per 1000 population. 9 Another major issue for Indonesia is the maldistribution and coverage of healthcare providers in various geographic areas. This is particularly true of the deployment of specialist physicians in rural and remote areas. According to PODES 2011 (Potensi Desa, Survey of Village Potential) 13 survey of Indonesia's 33 provinces, 30 did not meet the WHO recommended ratio of 1 doctor per 1000 population; however, virtually all villages in Java, the most populous island, have a doctor. While the central government has implemented a contract policy (Pegawai Tidak Tetap) to improve the distribution of healthcare providers-in particular, doctors, specialists, and midwives-across the country, geographical location of medical schools can reinforce the urban bias and maldistribution. 9 The absence of doctors and specialists from health facilities is another concern and can be a challenge to providing timely emergency obstetric services. Indonesia has previously been shown to have one of the highest absence rates for healthcare providers (doctors, nurses, and midwives) at 40%. 14 A study conducted in three districts in Indonesia between 2006 and 2008 showed that there has been a significant increase in the number of healthcare providers and the proportion of permanent public servants has increased even more than the increase in total numbers. 15 However, because doctor and midwife public servants are allowed to practice privately outside of office hours, there has also been an increase in the number of private practice facilities offering health care, potentially contributing to absenteeism from the primary place of public assignment. 15 Another study reported that between 65% and 80% of specialist physicians' income was derived from private practice in nonstate hospitals or private clinics. 16 Still another study indicated that despite regulations limiting practice locations to three facilities, most specialist physicians working in a provincial capital city were working in more than three locations, with some working in up to seven locations, and spending only a few hours per week in their government hospital practice. 16 While guidelines are available to recommend the number and types of healthcare providers who should be available in CEmONC facilities, Indonesia's highly decentralized health system hinders the government's ability to regulate the private sector or to enforce policies in public facilities. 16 The purpose of the present study was to describe doctors and obstetrician/gynecologists' availability to manage obstetric complications in hospitals in six provinces of Indonesia, by hospital type, geographical area, and referral case.

| Sample
A total of 1609 clinical observations of labor and childbirth practices were completed in the 13 hospitals. Among these, a total of 521 women who experienced complications of childbirth, including PPH (n=182 cases), severe pre-eclampsia/eclampsia (n=331 cases), or suspected maternal sepsis (n=11 cases), were included in this analysis. No maternal deaths were observed.

| Data analysis
We conducted an analysis of the distribution of providers by each cadre of worker, including the mean number of staff at each facility reported as an aggregate across all facilities, and by facility type (private and public). MOH public hospitals are categorized A-D, based on population served, and are staffed accordingly. Type A and B hospitals are found in districts with the largest populations with a minimum of 400 and 200 beds, respectively, and type D hospitals correspond to the smallest population and a minimum of 50 beds. 19 Based on their volume of childbirths, in this study, private hospitals were grouped with type D facilities. We also conducted an analysis of the presence of a doctor during the admission of a patient and on consultations with an ob/gyn for each patient admitted with any of three major maternal complications (PPH, pre-eclampsia/eclampsia, or maternal sepsis), and whether the consultation occurred in person, over the phone, or by short electronic messaging (SMS). The consultation type was not mutually exclusive, and observers could mark any that applied. For example, if a consultation occurred over the phone initially and then in person, then that case received a consultation by phone and in person.
We present results disaggregated by hospital type, province, referral status, and by time of day of provider consultation. Where there were enough cases to allow for analysis stratified by hospital type, province, referral status, and by time, we looked at differences in proportions using a χ 2 test with a level of statistical significance set at P<0.05.

Data from EMAS and comparison district facilities, and from 2015
and 2016 data collection time periods were collapsed into a single cohort, in an effort to provide a broad overview of how equipped CEmONC hospitals effectively managed the obstetric complications of interest. Importantly, the EMAS program did not directly target facility staffing directly; however, for the quasi-experimental pre-post control trial, data were collected on the numbers of providers registered at each facility. Given that only 11 cases were observed for maternal sepsis complication, disaggregated results are not shown for this specific complication.
The study team used Stata14 (StataCorp LLC, College Station, TX, USA) to manage and analyze all study data.

| Ethics
This project received approval from the Indonesia MOH and National Prior to each round of data collection, the study team conducted information sessions for the heads of these units and with healthcare providers from these wards regarding the facility observation process. An information sheet explaining the purpose of observing the management of these cases was provided. A provider's verbal consent to participate was obtained prior to the start of a clinical observation. All personnel involved with the evaluation received a session on ethical interaction with participants as part of the orientation and training schedule. Every effort was made to ensure the confidentiality of providers and the women experiencing complications.
Considerable variation was documented in the distribution of providers by province; Banten province had the highest number of ob/gyns, residents, and nurses, and West Java and North Sumatra has the highest number of general doctors.

| Availability of doctors and ob/gyns for women experiencing PPH or pre-eclampsia/eclampsia complications at hospitals, by referral status
Patients referred to a hospital for the management of PPH or preeclampsia/eclampsia were more likely to be seen by a doctor/resident than nonreferred cases (women who were in the same hospital for a routine delivery but then developed a complication), but were equally likely to have a consultation with an ob/gyn (Table 2). However, patients referred to a hospital for the management of pre-eclampsia/ eclampsia were more likely than women experiencing PPH to receive consultation, and also had higher levels of in-person consultation with an ob/gyn.
A total of 182 women experienced PPH during the period of observation ( Table 2). Among the 153 who were referred to hospital with PPH, less than half (47%) of these women were admitted to a hospital where a doctor/resident was available to assist with the emergency. In contrast, among nonreferred women, that is women who were in the hospital for a normal delivery and then developed PPH, doctors/residents were present at 24% of cases when PPH developed. Among all women who developed PPH during the observation period (n=182), about half (47%) received a consultation from an ob/ gyn, similar among referred cases (47%) and nonreferred cases (45%).
Of these, the majority of women received a consultation with an ob/ gyn over the phone or by SMS (61% and 18%, respectively), compared with in person (29%).
Of the 331 women who experienced pre-eclampsia/eclampsia during the observation period, 50% of women referred to hospital for management of this complication were admitted to a hospital where a doctor/resident was available to assist with the emergency, compared with nonreferred women, for whom doctors/residents were present at only 30% of cases when pre-eclampsia/eclampsia developed. The majority (76%) of all women with this complication received consultation by an ob/gyn. Among these, the most common type of consultation was by phone (57%), compared with in person (32%) and SMS (17%) ( Table 2).

| Availability of doctors and ob/gyns for women experiencing PPH and pre-eclampsia/eclampsia complications at hospitals, by hospital type
For women who experienced a PPH or pre-eclampsia/eclampsia complication, a higher proportion of patients in type B hospitals had access T A B L E 1 Registered healthcare providers by province, phase, and cadre of worker.

| Availability of doctors and ob/gyns for women experiencing PPH or pre-eclampsia/eclampsia complications at hospitals, by province
For both complications of PPH and pre-eclampsia/eclampsia, the patterns of doctor/resident availability and consultations with an ob/ gyn varied across provinces. Doctor/resident availability was highest among hospitals in Banten and Central Java province for both PPH and pre-eclampsia/eclampsia complications, and lowest among hospitals in East Java and South Sulawesi (Table 4). In contrast, there were higher rates of consultations with an ob/gyn occurring in North Sumatra and South Sulawesi compared with Java provinces for both The consultation type was not mutually exclusive and observers could mark any that applied. Therefore, if a consultation occurred over the phone initially and then in person, then that case received a consultation by phone and in person.
T A B L E 3 Availability of doctors and obstetrician/gynecologists for women experiencing postpartum hemorrhage or pre-eclampsia/ eclampsia complications at hospitals, by hospital type. The consultation type was not mutually exclusive and observers could mark any that applied. Therefore, if a consultation occurred over the phone initially and then in person, then that case received a consultation by phone and in person.  Abbreviations: Ob/gyn, obstetrician/gynecologist; PE/E, pre-eclampsia/eclampsia; PPH, postpartum hemorrhage. a The consultation type was not mutually exclusive and observers could mark any that applied. Therefore, if a consultation occurred over the phone initially and then in person, then that case received a consultation by phone and in person.

| Availability of doctors and ob/gyns for women experiencing PPH or pre-eclampsia/eclampsia complications at hospitals, by time of admission and/ or complication onset
experiencing PPH, with higher rates of consultation with an ob/gyn, particularly among women referred to hospitals for management of this complication. This may be explained by the differences between the clinical presentation, development, and management of these compilations, with pre-eclampsia/eclampsia typically progressing more slowly and managed through ongoing monitoring and intervention, while PPH is usually a more urgent and rapid diagnosis requiring an immediate response. Therefore, it is not surprising that women who were referred to hospital for the management of pre-eclampsia/ eclampsia were more likely to have either a doctor/resident available or be consulted by an ob/gyn compared with PPH cases that were referred, as providers usually had more time to attend this complication. Nevertheless, the low rate of doctor/resident on duty for nonreferred cases (25%) highlights a major challenge with ensuring provider availability when it is most needed.  across Indonesia. 9 The present paper highlights issues with provider availability and the provision of EmOC, which is further supported by results from the maternal death review by Baharuddin et al. 27 in this Supplement, in which the absence of ob/gyns from health facilities was identified as a contributing factor in 88% of the 90 cases reviewed.
Results from the present study support previous findings from other studies that highlight maldistribution of specialist physicians 13 and absence rates for health staff at 40% 14 as significant challenges to hospitals in Indonesia. These challenges are not unique to Indonesia.
A study conducted in Bangladesh 28  where the government has successfully encouraged more women to deliver in facilities but has not been able to ensure high quality of care.
A broader and more integrated policy approach including more innovative service delivery strategies for rural and remote areas is needed.

| Limitations
The EMAS evaluation study utilized a nonrandomized quasiexperimental design, rather than a randomized control trial design.
Nonrandom selection of facilities introduced the risk of selectivity bias in the quasi-experimental EMAS study, which influenced the analysis techniques used. However, as this study aimed to provide a descriptive overview of provider availability across hospitals in Indonesia, selection bias was minimized by collapsing both intervention and comparison sites together.
This small number of cases (sample size), especially when stratified by complication types, hospital type, referral status, and observation time, limited our ability to undertake any inferential analyses owing to low statistical power to find a significant difference. Also, as the primary outcome of the original evaluation study was not to assess provider staffing, only limited additional information was collected around reasons for the absence of doctors and specialists or lack of consultation. Specifically, the observational checklist did not aim to classify or quantify the severity of each observed complication, which may have had an impact on the decisions as to when an in-person specialist consultation was needed for each PPH or pre-eclampsia/ eclampsia complication observed. However, all observations occurred in hospitals designated as CEmONC facilities, which should have an emergency room doctor on call or available at all times. Observers were located in the emergency waiting rooms and labor and delivery rooms within hospitals to maximize the opportunity to identify all women who experienced pre-eclampsia/eclampsia, PPH, or sepsis. Observers also asked staff to alert them to instances when any of these complications occurred; however, there is the potential that facility staff or observers may have missed certain occurrences, potentially introducing some bias toward more or less severe cases being observed.

| CONCLUSION
Findings from the present study indicate that persistent issues of maldistribution of maternal specialists and high absence rates of both doctors and ob/gyns at the CEmONC hospitals during obstetric emergencies continues to undermine Indonesia's efforts to reduce high maternal mortality rates. 16 To address this issue, additional information should be collected to better understand factors that may affect provider availability at CEmONC hospitals, including facility-level management and policies and the potential influence of the growing private sector in luring away specialists from their duties at government hospitals.

AUTHOR CONTRIBUTIONS
AP led the design, planning, oversight, data analysis; MT and SQ contributed to the design, planning, oversight, data analysis; RS contributed to the planning. SA conducted statistical analyses and all authors contributed to manuscript writing and/or review.

ACKNOWLEDGMENTS
We would like to acknowledge the many women, newborns, and providers who participated in this study and enabled the collection of such important and sensitive information. We would like to thank the large data collection team for all their hard work and diligence, especially Mandri Apriatni and Sudirman Sudirman for overseeing and driving much of the data collection and management of the evaluation data.