Development of an Efficient and Effective Clinical Pathway for Cesarean Section in West Sumatra (Indonesia).

Introduction:  As with several countries around the world, cesarean section rates are increasing also in Indonesia, raising issues of quality and cost-effectiveness of health care, especially with the shift from a fee-for-service to a prospective payment system. For hospital services to be effective (quality control) and efficient (cost control), clinical pathways are essential. However, no studies have been done to develop a clinical pathway for cesarean sections (CS) in the INA-CBG system that is both effective and efficient. Objective: To develop clinical pathways for CS that are both effective and efficient by determining unit costs and tariffs for CS services, reviewing procedures and outcomes, and assessing performance efficiency and effectiveness. Methods: Using a sample of 110 patients undergoing cesarean sections consecutively recruited in 11 hospitals of West Sumatra (6 public hospitals and 5 private institutions), this mixed (qualitative and quantitative) study aimed at developing clinical guidelines for childbirth delivery modes responding both to criteria of efficacy and efficiency. Results:  Of 110 patients, 50 patients (45%) had efficient CS, 85 patients (77%) had effective CS, and 40 patients (36.4%) had both effective and efficient CS. A comprehensive clinical pathway for CS procedure was created by investigating 40 patients who underwent effective and efficient CS using interviews, a Delphi study, and professional advice. Discussion: Hospitals can adopt the effective and efficient clinical pathway for CS protocol to prevent cost-related losses (efficient) while retaining the quality of the service (effective).

Biomechanically Compliant Gynecologic Training Simulator.

INTRODUCTION: Pap smear training is commonly conducted using simulators before practicing with humans. Unfortunately, existing simulators do not well simulate the biomechanical properties of pelvic tissues, and this may negatively impact the training outcome. In this study, we used finite element analysis (FEA) to identify a material that most accurately simulates pelvic tissues in terms of biomechanical properties for fabricating gynecologic training simulators. The selected material was then used to fabricate a vagina and cervix model using a hybrid technique of fused deposition modeling and molding to qualitatively confirm the structural integrity of the simulator. METHODS: The vagina and cervix were reconstructed in a 3-dimensional feature according to geometrical parameters reported in the literature. The biomechanical compliance of the simulators was investigated by comparing 5 materials-RTV615, Dragon Skin 10, Dragon Skin 30, Dragon Skin FX-Pro, and Ecoflex 00-30-and a pelvic tissue model (control) using 2 FEA modules. The structural mechanics module simulated the insertion and opening of a vaginal speculum, and the (1) horizontal opening of the vagina and peak von Mises stress at the anterior and (2) posterior walls of the vagina were obtained. The explicit dynamics module estimated (1) the fracture stress during punch biopsies and (2) maximum perpendicular deformation of the cervix before break. The most biomechanically compliant material was subsequently used to fabricate the simulator using the hybrid technique. RESULTS: From the FEA, the horizontal opening of the vagina, peak von Mises stress at the anterior wall of the vagina, peak von Mises stress at the posterior wall of the vagina fracture stress, and maximum perpendicular deformation of the cervix before break were obtained; the results of Dragon Skin 10 and the control were most similar. Therefore, the simulator was fabricated using the material. A qualitative evaluation of the simulator by the naked eye verified its structural integrity. CONCLUSIONS: Of the materials studied, the FEA results showed that Dragon Skin 10 was the most accurate material for simulating pelvic tissues in terms of the biomechanical properties in a gynecologic training simulator. The simulator was also successfully fabricated using the hybrid technique. Further studies may also involve experimental testing to support the simulation results.

Cervical cancer burden, status of implementation and challenges of cervical cancer screening in Association of Southeast Asian Nations (ASEAN) countries.

Multiple barriers impede the transformation of evidence-based research into implementation of cervical cancer screening in ASEAN countries. This review is the first of its kind to show the disease burden of cervical cancer, progress till date to implement screening and corresponding challenges, and propose tailored solutions to promote cervical cancer prevention in ASEAN. In 2020, approximately 69 000 cervical cancer cases and 38 000 deaths happened in ASEAN, and more than 44% and 63% increases on new cases and deaths are expected in 2040. Only four countries have initiated population-based cervical cancer screening programs, but the participation rate is less than 50% in some countries and even lower than 10% in Myanmar and Indonesia. Inequity and unavailability in service delivery, lack of knowledge and awareness, limited follow-up and treatment capacity, and funding sustainability affect successful scale-up of cervical cancer screening most in ASEAN. Implementing HPV detection-based primary screening, appropriate management of screen-positives, enhancing health education, integrating health services can accelerate reduction of cervical cancer burden in ASEAN. Achieving high screening coverage and high treatment compliance will help ASEAN countries remain aligned to cervical cancer elimination strategies.

Urinary Tract Infections among Indonesian Pregnant Women and Its Susceptibility Pattern.

Pregnant women are usually at risk of urinary tract infections (UTIs) such as asymptomatic bacteriuria. In the current multidrug-resistance era, appropriate diagnosis and treatment should be provided to avoid complications in pregnant women in developing countries, which have limited facilities, such as Indonesia. The aim of this study was to evaluate in vitro susceptibility tests. Urinary isolates were collected from 715 pregnant women who visited eight Community Health Centers in Jakarta, Indonesia, between 2015 and 2017. We identified bacterial uropathogens from samples that were positive for nitrite/leukocyte esterase (LE), using two types of VITEK cards. Since noncompliance among patients is a major problem, fosfomycin-trometamol 3 g single-dose sachets were given to the patients, and the side effects of the medication and neonatal outcomes were reported. Asymptomatic bacteriuria was found in 10.5% of the 715 pregnant women. Escherichia coli was the most common etiological factor (26.7%), followed by Klebsiella pneumoniae (20%), Streptococcus agalactiae (9.3%), Enterobacter cloacae (5.3%), Enterococcus faecalis (5.3%), Staphylococcus saprophyticus (4%), Acinetobacter baumannii (4%), and others. Out of 76 pregnant women who took fosfomycin-trometamol, two complained of diarrhea that subsided without medication and fever that responded to paracetamol. Neonatal outcomes showed 100% full-term and normal-weight babies. E. coli, including extended-spectrum beta-lactamase- (ESBL-) producing E. coli, was 100% susceptible to fosfomycin. Nitrite/LE test results are often used as evidence for empiric antibiotic administration for treating asymptomatic bacteriuria in pregnancy, but the diagnosis should be confirmed using culture tests. Based on in vitro susceptibility patterns and medication outcomes, fosfomycin-trometamol single dose could be administered to noncompliant UTI patients, including pregnant women.

National screening programs for cervical cancer in Asian countries.

Cervical cancer is still one of the most common female cancers in Asia and the leading cause of cancer-related deaths in low- and middle-income countries. Nowadays, national screening programs for cervical cancer are widely provided in Asian countries. We reviewed the National Cancer Screening Program (NCSP) in China, India, Indonesia, Japan, Korea, and Thailand. The NCSP were established at varying times, from 1962 in Japan to 2014 in Indonesia. The primary screening method is based on cytology in all countries except for India and Indonesia. In India and Indonesia, visual inspection of the cervix with acetic acid (VIA) is mainly used as a primary screening method, and a "see and treat" strategy is applied to women with a positive VIA result. The starting age of NCSP ranges from 18 years in China to 30 years in Thailand. The screening interval is 2 years in all countries except for China and Indonesia, in which it is 3 years. Uptake rates of NCSP vary from 5.0%-59.7%. Many women in low- and middle-income countries still do not participate in NCSP. To improve uptake rates and thereby prevent more cases of cervical cancer, Asian countries should continue to promote NCSP to the public using various approaches.

Risk Factors for Neonatal Sepsis in Pregnant Women with Premature Rupture of the Membrane.

BACKGROUND: Premature rupture of the membrane (PROM) is associated with high maternal as well as perinatal morbidity and mortality risks. It occurs in 5 to 10% of all pregnancy while incidence of amniotic membrane infection varies from 6 to 10%. This study aimed to determine the incidence of neonatal sepsis in Cipto Mangunkusumo Hospital and the risk factors. METHODS: A cross-sectional study was done in Cipto Mangunkusumo Hospital, Jakarta, from December 2016 to June 2017. The study used total sampling method including all pregnant women with gestational age of 20 weeks or more experiencing PROM, who came to the hospital at that time. Samples with existing comorbidities such as diabetes mellitus or other serious systemic illnesses such as heart disease or autoimmune condition were excluded from the analysis. RESULTS: A total of 405 pregnant women with PROM were included in this study. There were 21 cases (5.2%) of neonatal sepsis. The analysis showed that risk of neonatal sepsis was higher in pregnant women with prolonged rupture of membrane for ≥ 18 hours before hospital admission (OR 3.08), prolonged rupture of membrane for ≥ 15 hours during hospitalization (OR 7.32), and prolonged rupture of membrane for ≥ 48 hours until birth (OR 5.77). The risk of neonatal sepsis was higher in preterm pregnancy with gestational age of <37 weeks (OR 18.59). CONCLUSION: Risk of neonatal sepsis is higher in longer duration of prolonged rupture of membrane as well as preterm pregnancy.

The Cost-Effectiveness of Quadrivalent Human Papillomavirus Vaccination in Indonesia

Objective: National cervical cancer prevention program has been initiated in Indonesia since April 2015 and the ministry of health has started efforts to integrate the HPV Vaccine in the national immunization program since Q4 2015. Thus, it becomes important to analyze the cost-effectiveness of HPV vaccine. The objective of this model is to examine the potential long-term epidemiologic and economic impact of quadrivalent HPV(qHPV;6/11/16/18) vaccination program in Indonesia. Methods: A previously validated transmission dynamic model was used to estimate the long-term epidemiologic and economic consequences of quadrivalent HPV vaccination by comparing cost-effectiveness of 2 dose qHPV vaccination strategy for girls 11-12 years old (with or without catch up; catch up dose for 12­26 years) versus Screening Only (Pap Smear) for reducing cost related to HPV type 6,11,16,18 (cervical cancer, CIN 1, CIN 2/3, and genital warts). Costs of an HPV disease episode-of-care (diagnosis and treatment) were calculated for base case analysis using local Indonesian cost. Result: 2-dose qHPV vaccination strategies without catch up reduce the overall incidence of HPV 16/18­related cervical cancer relative to screening by 54.4% over the 100 year following vaccine introduction. Likewise, vaccination strategies reduce the incidence of HPV type 16/18 CIN 2/3, CIN 1 by 69.1% and 71.8% respectively, also reducing HPV type 6/11 CIN 1, genital warts in female, genital warts in male by 82.9%,84.2%,82.1% respectively, at this time point. From total reduction of health care cost, 67.1% attributable for diseases caused by HPV type 16/18 and 32.9% attributable for diseases caused by HPV type 6/11. Without catch up, cost/QALY would be $450/year. However catch-up strategy is more cost effective versus vaccinates 12-year-old girls only; with cost/QALYs would be $390/year. Conclusion: HPV 6/11/16/18 vaccination of females in Indonesia are 1) substantially reduce genital warts, CIN, and cervical cancer; 2) improve quality of life, and 3) with the Indonesia GDP of USD 3,531.80 in 2014 , Cost/QALYs result with or without catch up is considered very cost-effective when implemented; however with catch up, the cost/QALY can be better.

Role of family support and women's knowledge on pregnancy-related risks in adherence to maternal iron-folic acid supplementation in Indonesia.

OBJECTIVE: To examine whether women's knowledge of pregnancy-related risks and family support received during pregnancy are associated with adherence to maternal iron-folic acid (IFA) supplementation. DESIGN: Secondary data analysis of the 2002-03, 2007 and 2012 Indonesia Demographic and Health Survey. Analysis of the association between factors associated with adherence (consuming ≥90 IFA tablets), including the women's knowledge and family support, was performed using multivariate logistic regression. SETTING: National household survey. SUBJECTS: Women (n 19 133) who had given birth within 2 years prior to the interview date. RESULTS: Knowledge of pregnancy-related risks was associated with increased adherence to IFA supplementation (adjusted OR=1·8; 95 % CI 1·6, 2·0), as was full family (particularly husband's) support (adjusted OR=1·9; 95 % CI 1·6, 2·3). Adequate antenatal care (ANC) visits (i.e. four or more) was associated with increased adherence (adjusted OR=2·2; 95 % CI 2·0, 2·4). However, ANC providers missed opportunities to distribute tablets and information, as among women with adequate ANC visits, 15 % reported never having received/bought any IFA tablets and 30 % had no knowledge of pregnancy-related risks. A significant interaction was observed between family support and the women's educational level in predicting adherence. Family support significantly increased the adherence among women with <9 years of education. CONCLUSIONS: Improving women's knowledge of pregnancy-related risks and involving family members, particularly the husband and importantly for less-educated women, improved adherence to IFA supplementation. ANC visit opportunities must be optimized to provide women with sufficient numbers of IFA tablets along with health information (especially on pregnancy-related risks) and partner support counselling.