Journal of Maternal and Child Health (2021), 06(02): 229-237 Research

Masters Program in Public Health, Universitas Sebelas Maret

Health Impact Assessment of Covid-19 Towards Maternal

Health Care in West Jakarta
Nisaatul Maharanita Fitrianingrum1), Sabarinah2), Hadi Pratomo3)
1)Postgraduate Student in Reproductive Health, Faculty of Public Health, Universitas Indonesia
2)Biostatistics
Department, Faculty of Public Health, Universitas Indonesia
3)Health Promotion and Behavioral Studies, Department Faculty of Public Health,

Universitas Indonesia

ABSTRACT

Background: The Large-Scale Social Restrict- by health personnel, and MCH services carried
ion Policy (PSBB) was implemented in DKI out at health facilities in West Jakarta were
Jakarta to reduce the spread of COVID-19 due beyond the control showed by there were no
to its highest ranked case in Indonesia. A moni- direct points above or below the median line.
toring program for Maternal and Child Health As with the trend, the four data showed no
(MCH) as well as Family Planning (FP) at Suku trend and zigzag pattern starting from the third
Dinas Kesehatan (Sudinkes) of West Jakarta data (March 2018) to the 26th data (January
was conducted during the pandemic. This study 2020) on the entire control chart.
was done to describe the impact of the COVID- Conclusion: COVID-19 impacted the decrease
19 pandemic towards MCH and FP services, as number of pregnant women’s visits, which
a basis for policy analysis and recommenda- coincided with the emergence of the first
tions for recovery or risk mitigation program on confirmed positive case of COVID-19 in West
COVID-19. Jakarta. A digital monitoring system to guide
Subjects and Method: This is a mixed- the problematic patients had ever imple-
method study with deductive sequential design. mented, therefore, recommendation proposed
Four indicators of the quantitative data was in this study was the reactivation of the digita-
obtained from routine data on the Pulih Covid lisation on maternal health monitoring system
dashboard and analysed using SPSS version 26 in West Jakarta.
become a control chart which was visualised
into graphs, while the qualitative data was Keywords: COVID-19, Maternal Healthcare,
obtained to investigate the reasons of changing Health Impact
trends from quantitative data as the impact of
COVID-19 on maternal health services using in- Correspondence:
depth interviews with responsible officers in Sabarinah. Biostatistics Department, Faculty of
Sudinkes of West Jakarta. Public Health, Universitas Indonesia. Depok
Results: In the indicators of visiting pregnant 16424, Indonesia. Email: sabarinahprasetyo@-
women (K1 and K4), delivery process assisted gmail.com. Mobile: +62816953885.

Cite this as:

Fitrianingrum NM, Sabarinah, Pratomo H (2021). Health Impact Assessment of Covid-19 Towards Maternal
Health Care in West Jakarta. J Matern Child Health. 06(02): 229-237. https://doi.org/10.26911/thejmch.-
2021.06.02.10
Journal of Maternal and Child Health is licensed under a Creative Commons
Attribution-NonCommercial-ShareAlike 4.0 International License.

BACKGROUND nesia were found in Jakarta, which later

The COVID-19 disease outbreak caused by identified in other large clusters. At that
the SARS-CoV-2 virus is designated as a time, there were only 1,000 cases nation-
public health emergency which is troubling wide at the beginning, of which 50% of
the world, including Indonesia. The first positive cases were from Jakarta. According
and the second cases of COVID-19 in Indo- to data reported on the website http://-

e-ISSN: 2549-0257 229

Fitrianingrum et al./ Health Impact Assessment of Covid-19 Towards Maternal Health Care

covid19.go.id, confirmed cases of COVID-19 pregnant women based on first visit to

have reached 858,043 as of January 13, health providers (K4) and last visit (K4)
2021 (Hirawan, 2020; Susilo et al., 2020; coverage, as well as delivery attendance by
Satuan Tugas Penanganan COVID-19, health personnel at health service facilities
2021). (Fasyankes). According to data on the
According to interview result with the health profile of DKI Jakarta in 2018, MMR
Sudinkes (District Health Office) of West in West Jakarta City in 2018 was 32 person
Jakartaofficer, the first COVID-19 case per 100,000 live births. Coverage of K1 and
which appeared in West Jakarta on March K4 tend to increase reaching 99.4%. The
4, 2020in Siloam Hospital, Kebon Jeruk. percentage of deliveries in health facilities
The trend of COVID-19 cases in West assisted by health personnel in West
Jakarta fluctuates, and tend to increase Jakarta continues to increase to 99.8%
every day. Data until September 2020 (Bidang Perencanaan dan Pembiayaan,
found that 460 health workers were 2018; Pokja Renstra Kemenkes 2020-2024,
affected by COVID-19 from 8 health centres 2020).
and 4 hospitals in West Jakarta. Moreover, The Large-Scale Social Restriction
there were 48 pregnant women with Policy (PSBB) was implemented in DKI
reactive results for rapid test, and 55 Jakarta aimed to reduce the spread of
pregnant women with positive PCR swabs. COVID-19 because Jakarta had the highest
61 cases of referred mothers with positive case in Indonesia. The first phase of the
swab delivered at the hospital, and it is PSBB began on 10 April 2020 and was
known that 17 cases gave birth at the Public extended three times (Gubernur Daerah
Health Centres or Puskesmas. Khusus Ibukota Jakarta, 2020). The
This outbreak had a significant impact Sudinkes of West Jakarta has made various
on various sectors of life, such as education, efforts to reduce the incidence of COVID-19
economy and tourism. Social distancing by following the policy of the Governor of
policy which requires everyone to keep DKI Jakarta using the 3T system (Testing,
their distance when interacting with anyone Tracing and Treatment), implementing and
for breaking the chain of transmission of monitoring the 3M protocol (Wearing
COVID-19 is one of the reason. Further- Masks, Keeping Distance, and Washing
more, the COVID-19 pandemic is also Hands). They alsohave prepared controlled
considered to have an impact on various isolation facilities such as hotels, guest
health sectors, particularly maternal and houses and sports buildings. Under super-
child health and family planning(Masrul et vision from the Provincial Chapter of the
al., 2020). Obstetrics and Gynaecology Association
In the health sector as stated in the (POGI Jaya), they prepare health centres to
Strategic Plan of the Ministry of Health assist labour for women with COVID-19. In
2020-2024, policy direction to improving addition, Sudinkes of West Jakarta has also
MCH services is still a top priority for prepared four hospitals as referral hospitals
health development in Indonesia. Access to for COVID-19, especially maternal and
MCH in Indonesia is potentially experien- infant health services.
cing obstacles during the COVID-19 pande- Based on the explanations above, a
mic. Several indicators regarding maternal monitoring of the MCH and Family
health services are including the maternal Planning program in the West Jakarta
mortality rate (MMR), health services for during the pandemic period needs to be

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Fitrianingrum et al./ Health Impact Assessment of Covid-19 Towards Maternal Health Care

done. The aim of this study was to deter- Jakarta health officer, as research infor-
mine both direct and indirect impacts mant of this study for qualitative
caused by the COVID-19 pandemic on information.
maternal health programs. In addition, this 3. Study Variables
was also seeks to answer questions regard- Dependent variables in this study was
ing the increase in maternal mortality due maternal health care,while the independent
to the COVID-19 pandemic which has been variable was COVID-19.
running for one year. The data were used as 4. Operational Definition of Variables
a basis for policy analysis and recommen- Maternal health care defined by services
dations for recovery or risk mitigation provided by Puskesmas in West Jakarta,
program related to COVID-19 pandemic. determined by four indicators such as K1
and K4 visits, deliveries assisted by health
SUBJECTS AND METHOD personnel, and deliveries carried out at
1. Study Design health facilities.
The approach used in this study is a mixed- 5. Study Instruments
method with a deductive-sequential design, Research instrument in the form of inter-
where quantitative data collection and view guide was arranged by the team of
analysis are carried out first, followed by Universitas Gadjah Mada.The interview
qualitative data collection and analysis. was conducted to investigate the reasons of
Study was placed in the West Jakarta changing trends from four indicators of
Administrative city from August to Decem- quantitative data as the impact of COVID-
ber 2020. The quantitative data was routine 19 on maternal health services.
data set sent by Sudinkes of West Jakarta to 6. Data analysis
the Ministry of Health. The routine data It was processed using SPSS version 26
management was a collaborating effort become a control chart which was visua-
between the Ministry of Health with lised into the four graphs of control chart.
Universitas Gadjah Mada and involving 7. Research Ethics
Universitas Indonesia. The data was Following the Helsinki declaration, prior to
provided through the PulihCovid19 dash- the interview, an informed consent was
board since January 2018 to June 2020. explained and approved by the selected
Furthermore, the qualitative data was informantsand Sudinkes of West Jakarta.
obtained through in-depth interviews with
the MCH officers from Sudinkes of West RESULTS
Jakarta. Information obtained from two In the four indicators of the control
officers from the Sudinkes of West Jakarta charts below, there were no direct points
who mastering the maternal and child above or below the median line. As with the
health (MCH) program on November 24, trend, the four data showed no trend and
2020. zigzag pattern. Data tends to fluctuate
2. Population and Sample starting from the third data (March 2018)
These were secondary data, which the to the 26th data (January 2020) on the
population of the study was all pregnant entire control chart. However, the four data
women in West Jakarta who did routine showed that there were two points that
visits in the Puskesmas in West Jakarta exceed the standard deviation in the 28 th
using total sampling. The routine data was data (April 2020) and the 29th data (May
documented by the Sudinkes of West 2020). In other words, on the indicators of

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Fitrianingrum et al./ Health Impact Assessment of Covid-19 Towards Maternal Health Care

visiting pregnant women (K1 and K4), deli- control. The data varies systematically,
very process assisted by health personnel, which means that there was a specific cause
and MCH services carried out at health that could possibly stem from the COVID-
facilities in West Jakarta were beyond the 19 pandemic.

Figure 1. Control Chart K1 (top left), K4 (top right), Deliveries assisted by health
personnel (bottom left), and delivery at health facilities (bottom right).

The number of visits by pregnant and offline maternal classes, coaching

women in the first trimester (K1) and programs, and facilitative supervision to
fourth visits (K4) in West Jakarta has private midwifery practices (BPM), and
decreased from March and experiencing its other on-going programs were done online
lowest point in April 2020. The assumption and offline. Offline programs were done by
that the decline in access of MCH services complying health protocols.
for pregnant women was due to the deter- Generally, the number of deliveries at
mination of PSBB in the first phase of the health facilities in West Jakarta area in
period from March to May. At that time, 2020 experienced a decline starting on
there were restrictions on the types of March, and reached its lowest point on
services and the number of visitors to the April when compared to previous years.
Puskesmas, as well as the delay in Posyan- The cause of the decline was due to the high
du activities, particularly located in the red mobility of the population in West Jakarta,
zone. Activities related to maternal and thus many migrants from other areas were
child health in West Jakarta that were still found. In addition, there were restrictions
running including, standardized ANC, on access to health facilities so that many
Acute Infected Prevention Program (PPIA), pregnant women also leave the Provincial
and triple elimination. Additionally, online Jakarta area.They move to their relatives in

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Fitrianingrum et al./ Health Impact Assessment of Covid-19 Towards Maternal Health Care

the areas considered in having relatively maternal health referral system. Monitor-
safe access to healthcare. In other words, it ing results show that the COVID-19 pande-
was a green zone areas which have not been mic has an impact on the implementation
affected by COVID-19. of planned maternal health services, espe-
The efforts executed by Sudinkes of cially on the four indicators analysed in
West Jakarta for childbirth were done by Sudinkes of West Jakarta.
creating WhatsApp group between hospi-
tals and reverse-referrals patients. They DISCUSSION
also activate triage for patients visiting the Previous studies on the indirect impact of
Puskesmas. In fact, in 2018, the Sudinkes the COVID-19 pandemic on MCH and
of West Jakarta has implemented a digital family planning services before and during
monitoring system. It monitors pregnant the lockdown showed that both mothers
and childbirth women with problems, start- and children are vulnerable to mortality
ing from the time when they arrived and and at risk of lack health services. The
sent home. The officers collaborated with reduced of service rates to more than half
local health workforces to provide gui- in hospitals and the decline in quality of
dance. However, at that time,the innovation care in Nepal was due to the weak health
was unable to be done to face the impact of system and policies related to lockdowns in
the pandemic as the consequence of the low and middle income countries (KC et al.,
absence of internet server, even though an 2020). COVID-19 has had an impact on
IT team at each Puskesmaswas already health services in various parts of the
available. The Puskesmas and Hospitals world, even in developed European
which were currently being tested were countries. In the UK, some areas reduced
Cengkareng and Kalideres areas because home delivery services and delivery centres
these areas had both higher maternal in obstetric care due to a limitation in
mortality rate and populations compared to health personnel. This area reduced access
others. to transfer of patients by ambulance as well
Other information related to maternal (Coxon et al., 2020).
deaths obtained from the MCH officer The report informed by the RMC
Sudinkes of West Jakarta found that the Global Councilstated that violence has
number of maternal deaths up to August affected of mothers and children’s health
2020 was 21 persons with 2 deaths during the COVID-19 pandemic. The
confirmed by COVID-19. In the early days deterioration of the health system, such as
of the COVID-19 pandemic, primary service lack of personal protective equipment for
facilities namely private midwivespractices health workers is one of it. In addition,
(BPM) had difficulty in making referrals to neglect and restrictions on emergency
hospitals. It was because when pregnant transport, antenatal and postnatal contacts,
women were referred to the hospital, they as well as facilities due to fear of contract-
had to attach the results of Rapid Diag- ing infectious diseases are also categorised
nostic Test (RDT), whose existence was still as the effects of COVID-19 on women's
limited. The existence of COVID-19 cases rights to get quality services. Furthermore,
among pregnant women were also caused there are changes in scientific evidence-
by the unavailability of a specific COVID-19 based service practices, unavailability of
maternal care rooms. This also caused by contraceptives and unequal access to alter-
the absence of a high-risk or complicated natives to telemedicine or mHealth are

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Fitrianingrum et al./ Health Impact Assessment of Covid-19 Towards Maternal Health Care

other risks that occur in society in general. Midwives in the three countries also
Not only in terms of patients, health care reported that the number of visits by
providers, patients, and families also lack of mothers to health services had also
adequate information on the impact of decreased because they were afraid of visit-
COVID-19, therefore, they need access to ing hospitals and being exposed to the
standardized evidence-based information coronavirus. In addition, they also feel
(Jolivet and et al, 2020). afraid to be tested for COVID-19 because if
Antenatal visits, immunisations, and the results are positive, they must be
delivery at health care facilities or hospitals quarantined away from their families. So
had decreased due to limited access to this leads mothers to arrive late to health
health services during lockdown and the care facilities, and ends with unexpected
imposition of curfews by the Kenyan results, such as premature delivery as well
government. This causes pregnant women as maternal and infant mortality. Thus, the
and their companions worry about going to Kenyan government organised a training
jail. Additionally, the fear of COVID-19 through an online platform and distributed
infection also causes women to avoid visits the protocol in health services (Pallangyo et
to reproductive health services. Community al., 2020).
midwives approach adopted to minimise The National Socio-Economic Survey
the gap and optimise MCH services during conducted by Statistic Indonesia showed
this crisis. The community midwife model that the use of internet in the household
is an innovative community-based health reached 73.75%, followed by the growth of
intervention that involves the skills of population using cellular phone which
midwives to provide maternal health reached 63.53%. During period 2015 –
services at home. Culturally, this service 2019, inhabitants who use internet keep on
can be accepted by the community so that it increasing from 21.98% until 47.69%
can increase the coverage of ANC services, (Statistic Indonesia, 2019). Until now,
family planning, HIV services, delivery by penetration of smartphone to Indonesian
health workers, postpartum services, and citizens is relatively high, and this trend is
exclusive breastfeeding. However, the projected to keep on increasing in the
success factor of this model depends on following years (Statista, 2019). Basically,
their familiarity with public health workers the Indonesian inhabitants use internet-
and adequate remuneration for services by disconnected smartphone for communica-
the government insurance scheme (Kimani tion, entertainment, business purpose, and
et al., 2020). study. Conversely, they use internet-
A study in Kenya, Tanzania and connected smartphone for communication,
Uganda found that maternal and child entertainment, browsing, studying and
mortality in these countries was consistent- working (KOMINFO, 2017). The usage of
ly high, and was exacerbated by the COVID- gadget by women in looking after their
19 condition. Midwives play an important children is not only give negative impacts,
role in saving the lives of mothers and such as decrease of children concentration
babies, which in these three countries are and kids’ aggressive behaviour, but also
still scarce and cannot reach service targets give positive impacts for them. Thepositive
even in normal situations. Another reason impacts of using smartphone are helpful in
is that mothers who are pregnant or expect- taking care their children, communicating
ant mothers cannot afford health services.

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Fitrianingrum et al./ Health Impact Assessment of Covid-19 Towards Maternal Health Care

with them, and happiness feeling (Khusma acceptance in term of convenience usage
and Kahija, 2017). perception andbeneficence perception. In
A study conducted by Lupton and contrast to this, staff shortages, time
Maslen (2019) found that Australian constraints, patients urgency, connectivity
women from different ages, geographical issues and function of the software are still
locations, and education levels are using the be the barrier (Usmanova et al., 2020).
spectrum of digital technologies to control Another study from the patients’
their health and well-being. In other words, experiences, 10 of 11 pregnant women had
the usage of gadgets by Australian women positive perception related to birth plan app
were much more interesting, rather than from the communication sides and they like
using traditional media such as books or it. Moreover, from the patients’ process-
printed pamphlets. Digital health informa- related perception, this app assumed as
tion technologies accessed by them were learning, care improvement, practicality,
varies, such as Google Search, health and speed, convenience and self-monitoring
fitness apps, social media, other fitness media.
trackers and Apple Watch. In this study, To sum up, there had been a decline
women from every backgrounds said that in the number of services starting in March
they went online regularly and they joined and reaching its lowest point in April, 2020
peer communities which known as patient which coincides with the emergence of the
support forums as well(Lupton and Maslen, first confirmed positive case of COVID-19
2019). in West Jakarta. The causes of the decrease
Digitalisation using mobile-health in the number of visits were the existence of
technologies gave significant impact in PSBB, a reduction in the number of services
improving health care services and delivery in primary health care facilities, and the
processes. Experiments done in this rese- existence of the community's stigma against
arch show some promising results for clini- the incidence of COVID-19 in Indonesia.
cal management, appropriate testing, The recommendation given to the Sudinkes
referral, screening, diagnosis, treatment, of West Jakarta was to review a policy
and triage. Even though in developing regarding reactivation of the digital moni-
countries, management support is the most toring system (e-cohort) related to health
relevant impact for clinical support as well conditions of mothers and children that
as evidence-based guidance in healthcare have been carried out previously. In addi-
(Free et al., 2013). A cross-sectional study tion, Sudinkes required to work together
related to mobile phones usage for health with the SukuDinas for Empowerment for
communication concluded that women who Child Protection and Population Control of
use cell phones had preferences to go to West Jakarta to provide disseminate infor-
professional delivery (54.2%) rather than mation to health cadres in West Jakarta.
who did not use it (95% CI 51.8 – 58.5) The limitation of this research was merely
(Tang et al., 2019). focused on maternal health in specific
A study regarding acceptability and place, therefore, research in other places
barriers of electronic platform for Peri- might have different impact caused by
partum was conducted in India, show that COVID-19 pandemic. Further study related
this digital platform is user-friendly, to acceptance of pregnant women to be
effective, and sustainable. For the health monitored using digital system is recom-
workforces, there were high generally

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Fitrianingrum et al./ Health Impact Assessment of Covid-19 Towards Maternal Health Care

mended to do since there is limited study Free C, Phillips G, Watson L, Galli L, Felix
related to this information. L, Edwards P, Patel V, Haines A
(2013). The effectiveness of mobile-
AUTHOR CONTRIBUTION health technologies to improve health
Nisaatul Maharanita Fitrianingrum collect- care service delivery processes: a sys-
ed and analysed the data as well as drafted tematic review and meta-analysis.
the manuscript, Sabarinah and Hadi PLoS medicine. 10(1): e1001363. doi:
Pratomo provided critical revisions of the 10.1371/journal.pmed.1001363.
text. All authors have read and approved Gubernur Daerah Khusus Ibukota Jakarta
the final submitted version. (2020) Peraturan Gubernur Daerah
Khusus Ibukota Jakarta Nomor 33
CONFLICT OF INTEREST tahun 2020 tentang Pelaksanaan
The authors declare that they have no
Pembatasan Sosial Berskala Besar
potential conflict of interest in performing
dalam Penanganan Corona Virus
this analysis.
Disease 2019 (COVID19) di Provinsi
Daerah Khusus Ibukota Jakarta.
FUNDING AND SPONSORSHIP
None. Hirawan FB (2020). Indonesia dan covid-
19: pandangan multi aspek dan
ACKNOWLEDGEMENT sektoral. Jakarta: CSIS Indonesia.
Special thanks were given to the Provincial Jolivet RR, Warren CE, Sripad P, Ateva E,
Health Office of Jakarta and the Sudinkes Gausman J, Mitchell K, Hacker HP, et
of West Jakarta for supporting the availa- al (2020). Upholding rights under
bility of routine data on MCH services as COVID-19: The respectful maternity
well as to be informants in the imple- care charter. Health Hum Rights,
mentation of qualitative data collection in 22(1): 391–394. https://www.ncbi.-
this manuscript. Thanks are also given to nlm.nih.gov/pubmed/32669827.
Prof. Laksono Trisnantoro and team who Kc A, Gurung R, Kinney MV, Sunny AK,
have involved us in conducting this Moinuddin, Basnet O, Paudel P, et al.
program. (2020). Effect of the COVID-19 pan-
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