Care-seeking and health insurance among pregnancy-related deaths: A population-based study in Jember District, East Java Province, Indonesia.

BACKGROUND: Despite the increased access to facility-based delivery in Indonesia, the country's maternal mortality remains unacceptably high. Reducing maternal mortality requires a good understanding of the care-seeking pathways for maternal complications, especially with the government moving toward universal health coverage. This study examined care-seeking practices and health insurance in instances of pregnancy-related deaths in Jember District, East Java, Indonesia. METHODS: This was a community-based cross-sectional study to identify all pregnancy-related deaths in the district from January 2017 to December 2018. Follow-up verbal and social autopsy interviews were conducted to collect information on care-seeking behavior, health insurance, causes of death, and other factors. FINDINGS: Among 103 pregnancy-related deaths, 40% occurred after 24 hours postpartum, 36% during delivery or within the first 24 hours postpartum, and 24% occurred while pregnant. The leading causes of deaths were hemorrhage (38.8%), pregnancy-induced hypertension (20.4%), and sepsis (16.5%). Most deaths occurred in health facilities (81.6%), primarily hospitals (74.8%). Nearly all the deceased sought care from a formal health provider during their fatal illness (93.2%). Seeking any care from an informal provider during the fatal illness was more likely among women who died after 24 hours postpartum (41.0%, OR 7.4, 95% CI 1.9, 28.5, p = 0.049) or during pregnancy (29.2%, OR 4.4, 95% CI 1.0, 19.2, p = 0.003) than among those who died during delivery or within 24 hours postpartum (8.6%). There was no difference in care-seeking patterns between insured and uninsured groups. CONCLUSIONS: The fact that women sought care and reached health facilities regardless of their insurance status provides opportunities to prevent deaths by ensuring that every woman receives timely and quality care. Accordingly, the increasing demand should be met with balanced readiness of both primary care and hospitals to provide quality care, supported by an effective referral system.

Balance Nutrition Messages Are Still Implemented in Preschools One Year Postintervention: Case Studies in Subang District, West Java, Indonesia.

Thirty-two teachers from 10 preschools in Cisalak subdistrict, Subang district, West Java province, Indonesia, received a two-day training on Balance Nutrition and My Plate in February 2018. The main messages underlined in the training were consume a variety of foods, drink enough water daily, wash your hands with soap, be physically active, and monitor your body weight. The training was followed by an eight-week implementation period to preschoolers aged 3 to 6 y. The knowledge of the teachers increased by up to 33 percentage points (average score: 69 to 82 pre- vs. posttest) after training, and the teachers answered correctly to the same questions 15 mo later. The mothers' knowledge increased by up to 37 percentage points after parenting sessions. All seven teaching aids provided were used by end-line, but their usage decreased after seven months (range: 2 to 7) and further decreased by 12 mo postintervention (range: 2 to 5). A teacher's handbook and a flipchart were the two aids persistently used. The practices of washing hands with soap, bringing healthy packed lunches, and monitoring weight and height continued after 12 mo postintervention. Dissemination of Balance Nutrition knowledge to fellow teachers of the same school, colleagues from different schools, or to representatives of preschool associations was evident. Training should be scaled up to the district level, using trained teachers as trainers and adopting a cascade training method. National roll-out by teachers' associations, in collaboration with the Ministry of Education and the Ministry of Health, could improve the knowledge of over 200,000 preschool teachers and potentially improve the nutrition of 19 million preschoolers.