Attracting and retaining village midwives in Indonesian remote postings: 'Success cases' from West Nusa Tenggara

Abstract

“When midwifery is in place, there is much less need for emergency interventions.” - Petra ten Hoope-Bender at Bulletin WHO (Shetty, 2013)

Accessing health professionals, such as midwives, is essential reducing the maternal and child mortality rates. However, attracting and retaining midwives to remote areas of Indonesia is not a simple task. Many midwives in Indonesia prefer to work in cities due to better facilities, incomes, and proximity to families. In order to increase their numbers in remote areas, policy-makers and other related stakeholders must better understand those factors that attract them to, as well as retain them in, these remote areas.

This study explored key success factors that influenced midwives to work and stay in remote areas of Indonesia, and the policies of the Government of Indonesia (GoI) which influenced their attraction and retention to such areas.

The ‘Success Case’ evaluation method was used with Appreciative Inquiry. This combined approach has not been used before in the field of public policy to study health professionals in marginalised areas. However, it enabled the identification of key success factors from the best performing cases in order to obtain better evidence, thus assisting policy-makers and other related stakeholders to craft better strategies for attracting and retaining midwives in remote areas of Indonesia.

The West Nusa Tenggara (Nusa Tenggara Barat or NTB) Province was chosen as the study location because it provided an excellent opportunity to examine the ‘success cases’ (six districts) and the ‘less success cases’ (two districts) which were determined based on the coverage of midwives from 2010-2014. Fifty-seven participants from the ‘success cases’, fourteen participants from the ‘less success cases’, and four other relevant participants were interviewed. These included civil servant midwives, nationally- and regionally-contracted midwives, volunteer midwives, and national and local government officials. Thematic analysis included the voice of the government officials, and documents analysis as part of data triangulation. A multifaceted framework which consists of personal, organisational and societal factors was used as the conceptual framework for this study.

While some of the results were similar to previous studies, this study revealed some unique factors. Economic stability attracted midwives to remote areas in both the ‘success cases’ and the ‘less success cases’. Community support played a major role in their retention. Personal, family and individual prestige were identified as other important factors influencing midwives to stay in remote areas. Cultural and religious beliefs constructed midwives’ viewpoints about their work and life in general, which influenced their motivation.

It was found that many government programmes focus only on a limited number of policy initiatives, such as monetary incentives, to influence workers’ behaviours, and neglect the potentially important role that other, non-monetary factors may be playing. Policy-makers need to consider a broad range of motivational determinants which could potentially improve programmes and policies for attracting and retaining midwives in remote areas of Indonesia.

This study concludes by offering recommendations for the GoI in order to improve the recruitment and retention of midwives in remote areas of Indonesia, and suggests further areas for research.