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ngaging a village to be alert forobstetrical emergencies may seemunusual to families in the West,where health care, resources, and

education lead to low maternal mortalityrates. But in Indonesia, where about twowomen die each hour as a result ofpregnancy and childbirth, it indeed takesa village to help women survivepregnancy and childbirth.

Indonesia’s SIAGA (alert) initiativeinvites and implores everyone to play apart in helping to save women’s lives.SIAGA—an acronym of SIap (ready),Antar (take, transport), jaGA (stand by orguard)—began in 1998 under a UNFPA-funded program with the Ministry forWomen’s Empowerment and JohnsHopkins Bloomberg School of PublicHealth/Center for CommunicationPrograms (CCP). The original massmedia campaign—Suami SIAGA—focused only on husbands and their rolein preparing for delivery. Evaluationresults from Suami SIAGA were soimpressive that shortly after the UNFPAproject ended, the five-year Maternal and

Neonatal Health (MNH) Programexpanded and continued the program.The U.S. Agency for InternationalDevelopment (USAID) supportedMNH, which ended in June 2004.

Mobilizing for

AN ALERT VILLAGE

“Today we always have one or two

cars ready to rush pregnant women

to the hospital in case of

complications,” said M. Surjaya, the

village chief of Kedungsana, West

Java. “The cars belong to our

residents and they lend them to us

at night.” A list of 75 blood donors

hangs on the wall of his office. “If a

hemorrhage happens, we’ll ask the

donors to donate their blood,” he

said. Mr. Surijaya lists these

seemingly simple steps to illustrate

the importance of cooperation in

responding to obstetric emergencies.

His village is a self-described Desa

SIAGA (alert village).

SEPTEMBER 2004

To learn more about this project contact:Anne Palmer Senior Program Officer, CCPapalmer@jhuccp.org or Suruchi Sood Senior Program Evaluation Officer, CCPssood@jhuccp.org.

Indonesian singer Iis Dahlia (left)became a spokeswoman for theSIAGA campaign by singing atcampaign events while pregnant andappearing on campaign materials.

Indonesia’s SIAGA Campaign

Promotes Shared Responsibility

E

JHPIEGO, an affiliate of Johns HopkinsUniversity, CCP, and the Program forAppropriate Technology in Health(PATH) implemented MNH inIndonesia.

Of the 4.5 to 5 million women thatgive birth in Indonesia each year,approximately 18,000 die as a result ofpregnancy and childbirth. The MNHProgram in Indonesia worked to improvematernal and neonatal survival byexpanding interventions to prevent andmanage complications such as severebleeding in pregnancy and childbirth.

The Indonesian government investedheavily in village midwives during the1990s by training thousands who are nowdeployed all over the country. The MNHProgram’s behavior change componentpromoted midwives as skilled providersfrom whom women should seek carefrom during pregnancy, childbirth, andpostpartum. The program encouraged allpregnant women, their families, and their

communities to be prepared for birth andpossible complications.

Whereas the concept of communityinvolvement in maternal health washistorically strong in Indonesia,interventions did not necessarily reflectthe communities’ need. Indonesia’semerging democracy expandedcommunity involvement from a centrallydriven, message-dissemination network toengaging the community through theemerging civil society and NGOs. In acountry like Indonesia, where the reachof television and radio extends to far-flung islands and remote villages, massmedia plays an important role ininstigating social change. The MNHProgram had a variety of complementarymultimedia and community mobilizationactivities to support its objectives. Foreach of the intended audiences, theprogram identified a set of behaviors thatmake a person SIAGA. The SIAGAconcept built on the notion of sharedresponsibility, which is central to theIndonesian value of Gotong Royong orcommunity self-help.

Gotong Royong

Shared responsibility is at the heart ofMNH’s Birth Preparedness andComplications Readiness (BP/CR)strategy to reduce delays that can be fatal.Since delays can occur at different timesand places, preparedness and readinessmust therefore occur at different placesand involve a variety of people andplaces. Under the SIAGA initiative, thecore BP/CR behaviors/interventions arerecognizing danger signs and preparingfor childbirth by saving funds, arranging

for transportation to a health facility ifnecessary, and identifying a skilledprovider and birthing place.

Successful communication strategiesrequire extensive preparation before theyare implemented. The impact evaluationof Suami SIAGA (alert husband) in 2000and the baseline assessment in six WestJava districts in 2000-2001 providedinsights and recommendations for thedevelopment of the subsequent WargaSIAGA (alert citizen) and Bidan SIAGA(alert midwife) campaigns. A localadvertising agency assisted in specificmessage development while MNHstakeholders provided input into thecreative concepts for Bidan SIAGA andWarga SIAGA. The Indonesian MidwivesAssociation (IBI) and the Ministry ofHealth at the district and provincial levelprovided technical expertise. A localadvertising agency conducted pretests toensure that intended audiences (wives,husbands, midwives, and communityleaders) understood and liked the creativematerial. Just before printing,distributing, and airing the materials, thebehavior change team presented thewhole set of SIAGA materials tostakeholders for final feedback andapproval.

Launched between 1999 and 2002,each phase of the SIAGA campaignshared a common look but haddistinctive goals and approaches. PopularIndonesian singer Iis Dahlia served as thespokesperson through all phases of theSIAGA campaign. Suami SIAGA focusedon promoting the husband’s involvementin pregnancy, preparation for delivery,and any potential emergency. WargaSIAGA encouraged individual citizens to

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A village leader is interviewed andsurrounded by men wearing hatspromoting Suami SIAGA (AlertHusband).

be alert and prepared for delivery bydoing their part in arranging fortransport, funds, a blood donor, andrecognizing danger signs. Bidan SIAGApromoted the midwife as a skilled andfriendly provider prepared to helpthroughout the pregnancy. As a result,SIAGA became the brand name for safemotherhood in Indonesia.

Desa SIAGA

To ensure that women and families seekskilled providers at the time of birth, agrassroots participatory process led to thecreation of 55 Desa SIAGAs, or alertvillages, in MNH Program areas. A totalof 566 village facilitators played a centralrole in organizing birth preparedness andcomplication readiness actions withintheir communities. Strong politicalcommitment from diverse stakeholderssupported the community actionsthrough the White Ribbon Alliancemovement while communicationcampaigns helped raise communityawareness. Within the 55 MNH-supported villages, 226 hamletsestablished all four components of the

Desa SIAGA system — pregnancynotification to a midwife, emergencyfund plans, transportation, and blooddonation mechanisms. Desa SIAGA is amodel to make pregnancy a commonresponsibility for family and communityrather than solely the woman’sresponsibility.

Impact

Researchers conducted a baseline surveyin April 2001 with face-to-face interviewsof mothers, husbands, midwives, andcommunity leaders in the three coreprogram districts of Kota Cirebon,

Kabupaten Cirebon, and KabupatenKuningan, as well as three additionaldistricts - Bandung, Sukabami, andPurwakarta. They conducted a similarfollow-up survey in February 2004 in thesame six districts. Overall, the SIAGAcampaign had a powerful impact on theintended audiences. Evaluation resultsindicate that almost three-fourths of therespondents exposed to the campaignagreed that the SIAGA information wasrelevant and they were able to apply it totheir lives. Some 62 percent ofrespondents were exposed to the overallSIAGA campaign, measured in terms ofexposure to either Bidan, Warga or DesaSIAGA. Additionally, the fairly high levelof interpersonal communicationregarding SIAGA messages reported by 51percent of respondents indicates thatSIAGA sparked interest and discussionamong respondents’ social networks.

Researchers found clear differences inknowledge and practices pertaining toBP/CR among respondents before andafter the campaign, as well as amongunexposed and exposed respondentgroups at follow-up, across all keyindicators. For instance:

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• Knowledge of bleeding as a danger sign in the postpartum period:Women exposed to the SIAGAcampaign were significantly morelikely than those not exposed (29 percent and 10 percent respectively) torecognize severe bleeding as a danger sign during the postpartum period.

• Knowledge of plans in the community in order to prepare for safe childbirth: Researchers also foundsignificant increases in knowledge byboth women and men of all community plans (transportation, finances, blood donor, and notification) between the baseline and follow-up. Further, those exposed to the campaign were significantly morelikely to be aware of plans than those not exposed to the SIAGA campaign.

• Planning for transport, funds, and ablood donor, and letting others in the community know when a woman expected to deliver:

Overall, researchers found that womenand husbands exposed to the SIAGA

campaign were significantly morelikely to report making arrangements for safe childbirth. For example, in the case of funds for an emergency during childbirth, a substantial 63 percent of women exposed to the campaign acknowledged using this plan, compared to 37 percent of the women not exposed.

• Place of childbirth and type of assistance during childbirth:Overall, place and type of assistance at childbirth did not vary substantially between the baseline and follow-up.These results were not surprising, giventhe fairly high levels of reliance on skilled attendants reported at baseline (64.4 percent for women and 65.5 percent for husbands). However,women exposed to the campaign weresignificantly more likely than the non-exposed to use a skilled attendant at childbirth (Figure 2). Conversely,women and husbands exposed to the campaign were less likely to use traditional birth attendants (TBAs)

during delivery. Twenty-seven percent ofexposed women reported using TBAs,compared to 54 percent of non-exposedwomen, and 20 percent of husbandsreported using TBAs, compared to 56percent of non-exposed husbands.

These results indicate that the SIAGAcampaign played an important role inmaking Indonesian women, theirhusbands, and their communities moreprepared for complications duringpregnancy and delivery. The MNHProgram successfully engaged villages inpreparing for obstetrical emergencies andhelped make motherhood safer forwomen living in Desa SIAGAs.

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Mobilizing for Impact

summarizes key research findingsfrom the Maternal and Neonatal HealthProgram of JHPIEGO, an affiliate ofJohns Hopkins University, in partnershipwith the Center for CommunicationPrograms based at the Johns HopkinsBloomberg School of Public Health.

Johns Hopkins UniversityBloomberg School of Public HealthCenter for Communication Programs111 Market Place, Baltimore, MD 21202Tel (410) 659-6300, Fax (410) 659-6266Website: www.jhuccp.orgKim Martin, CCP EditorRita Meyer, CCP Graphic Designer

JHPIEGO - An Affiliate of Johns HopkinsUniversity

Funded by the U.S. Agency forInternational Development

An obstetric emergency during videotraining in the Warga SIAGA (AlertCitizens) campaign.