Midwives and Maternal Mortality: How Effective Has Indonesia’s Village Midwife Program Been?. Shailender Swaminathan (Brown) Tomoya Matsumoto (GRIPS) Jeffrey B. Nugent (USC) March 2010. I. Motivation.
Tomoya Matsumoto (GRIPS)
Jeffrey B. Nugent (USC)
Absence of reliable reports on MMRs since majority of deliveries are at home
Those programs which have been studied have had inadequate controls
Absence of useful randomized trials
MMRate = Maternal deaths at t /100K Women aged 15-49
Sisterhood Method (WHO 2004) Females asked to identify female siblings born of same mother, living or dead. If dead, asked to identify cause of death, if during pregnancy or within 2 mos. Post-partum.
This done at national, rural, urban and province levels
Fraction of districts with village midwife (VMP)
at national, rural, urban, province levels since 1975 using data from IFLS 1993, 1997, 2000.
* Other Controls: Age of woman, income, education of mother, time, alternative service provision
MMRater-ut= α0+ α1time +α2VMP+ α3Xr-u t +ut(1)
Midwife r-ut = β0 +β1time+ β2VMP + β3Xr-u t +v t (2)
RRRRURAL RR Shortcomings Noted
Almost 11 percentage point reduction in means of w/o adjusting for midwife availability (col. 2)
But after controlling for midwife availability, only a 3% fall (col. 4)
Hence over 70% of the fall in rates can be explained by VMW availability
Explanatory variables: linear time trend, fraction of districts with VMW, province level fixed effect
Table 2 shows that VMW availability explains 6% of intra province changes in MMRate. Use this to predict the MMRates by province Figure 3
For the provinces that are most substantially rural the drops are very sharp whereas the most urban least affected by the VMP, there is virtually no decline.
Other access differentials between rural and urban areas
Changing the date of startup of the program
Indonesia has made significant progress to MDG Goal for 2015
But by no means enough to achieve it
Despite small numbers of data points available , most of the decline achieved seems to be due to VMP
Possible areas for improvement over time
Possible areas for future research
Much could be done to improve it
But, even if the payoff in MMRate is deemed insufficient to justify it, because of other benefits that have been documented, such as on birth weights, child health, increasing BMI of women, increasing child spacing and reducing fertility rates, overall benefits might well outweigh the costs.