By Melva Moureen Aritonang, Communications Specialist in Jhpiego’s Indonesia office

For women living on remote islands in Indonesia, the world’s largest archipelago, childbirth can be daunting, particularly when complications arise. A referral or transfer to a higher-level health facility on a different island may require a long boat ride. This is what happened with Wagante, a 24-year-old, first-time mother from Pemana village, located on a small island off the larger island of Flores, in East Nusa Tenggara Province.

When Wagante learned she was pregnant, she visited Puskesmas Teluk, her local primary health facility, for her antenatal check-ups.  As planned, she returned to the puskesmas to deliver her baby. After 24 hours of labor, her contractions were not strong enough to push the baby out. Then her blood pressure began rising rapidly, increasing the risk of seizure and severe harm to Wagante and her baby. The attending doctor knew Wagante needed a higher level of care than the facility could provide.

While working to stabilize Wagante’s blood pressure, the doctor instructed Midwife Ekawati to initiate the referral process. Ekawati had recently been trained to use the government’s integrated digital referral system—an application called Sisrute—and knew what to do.

Without losing a minute, Ekawati rushed to the “signal tree” in the backyard of the puskesmas—the only place with a strong internet signal—to connect with TC Hillers Hospital, the referral facility. “I entered the data about Wagante’s condition into Sisrute,” said the midwife. “Not long after that, the ob-gyn of TC Hillers Hospital contacted the puskesmas doctor and advised us to immediately refer Wagante to TC Hillers Hospital for a cesarean section. I entered the ob-gyn’s advice into the application.”

A strong and efficient referral system can save precious time and lives. Midwife Ekawati had been trained to use the Sisrute application by the MOMENTUM Country and Global Leadership project, which aims to reduce maternal and newborn mortality rates by 30 percent at public health facilities across 22 districts in Nusa Tenggara Timur Province. A key strategy to achieve this target is by improving referral networks, so that patients receive timely care at the health facilities.

Indonesia’s government manages Sisrute; MOMENTUM aims to accelerate the use of the system through training and individual coaching for health workers. As of September 2022, MOMENTUM has supported the use of Sisrute across 26 hospitals and 126 primary health centers in 22 districts in Nusa Tenggara Timur Province, training 538 health professionals on its use.

With the go-ahead from TC Hillers Hospital, Wagante, along with her husband and in-laws, started the two-and-a-half hour boat ride to the hospital in Maumere, the largest city on the island of Flores. Two midwives from the puskesmas also traveled with Wagante to keep a close watch on her condition and contacted Public Safety Center (PSC) 119, the emergency response service established in Indonesia by the Ministry of Health.

An ambulance from PSC 119 was already waiting at the dock in Maumere to transport Wagante and her family to TC Hillers Hospital. “PSC 119 helps a lot in coordination and communication for transporting referral patients,” said Margaretha, an officer of PSC 119.

Midwives at the hospital had already prepared the operating room and contacted the doctor who would assist in the delivery of Wagante’s baby. “Sisrute speeds up the referral process, especially because there is an alarm that sounds like an ambulance, so we in the maternity ward get notified,” said Tanti, a midwife at the maternity unit in TC Hillers Hospital who was also trained by MOMENTUM to use the referral application. “We are ready when the patient comes to the hospital. A simple but very big change.”

Wagante gave birth to a healthy baby boy, Ode Alfan Al-ikhsan. Wagante and Ode were the first mother and baby to benefit from Sisrute following a referral from Puskesmas Teluk to TC Hillers Hospital.

Sisrute plays an important role in addressing delays in reaching a health facility that can provide the care they need. “Now, it is easier for the puskesmas to make referrals, and minimize delays in handling patients,” said midwife Tanti. “With Sisrute, even though the patient is far away, we know they are coming.”