Post-Training Evaluation on the Training of Basic

Obstatric and Neonatal Emergency Service Training

Eva Kartikasari1, Siti Nurchasanah2, Wardoyo3

{[email protected], [email protected], [email protected]}

Quality Control Unit of the Semarang Health Training Center (Bapelkes) 1,2,3

Abstract. PONED Training is an effort to decrease Mother and Infant Mortality Rate in
Central Java which the effectiveness was assessed through post-training evaluation. The
aim was to describe the implementation of the training at the workplace. The study used
mixed method with concurrent triangulation strategy. Subjects of the study were the
participants of the training in 2014 from 10 health centers selected by purposive
sampling. The results showed that the average knowledge of the respondents about the
training material was approximately 79.5; Respondents' compliance in applying skills of
preparation for obstetric-neonatal emergency was 96.3% while skills of stabilization,
referral, and transportation of newborns were 25%. Respondents were mostly proficient
in handling cases of post partum hemorrhage and hypertension-pre eclampsia (90,9%),
while the cases of hyperbilirunemia were the less controllable (27.3%); The implication
of the study was to provide information whether the training was beneficial or not and to
design better training.

Keywords: Evaluation; Post-Training Evaluation, PONED

1 Introduction

The Maternal Mortality Rate (MMR) in Indonesia is still high at 359/100,000 KH and the
Infant Mortality Rate (IMR) reached 32/1000 KH [1], in health problem areas (DBK)
including remote areas, borders and islands (DTPK) which was not affordable by health
workers and adequate health facilities. Likewise, MMR in Central Java Province from the data
of the Central Java Provincial Health Office in 2014 continued to increase. In 2013 there were
668 cases, 2012 (675 cases), 2011 (668 cases), and 611 cases of maternal deaths occurred in
2010. "The highest maternal mortality rate occurred in Brebes Regency with 73 cases, followed by
Tegal with 47 cases, Grobogan 43 cases, Pemalang 40 cases, and Pekalongan 39 cases"[2]. One of the
efforts to reduce MMR and IMR, the government announced in the 2010-2015 Strategic Plan
of the Ministry of Health stipulating that all District Health Centers in Indonesia must provide
Basic Obstetric Neonatal Emergency Services (PONED) for 24 hours.
The implementation of PONED based on data from Bappenas [3] had some problems,
such as maternal and neonatal complications just passing through in the clinic to get a referral
to a hospital, midwife or village midwife much that refer directly to the Hospitals (mainly to
private services) without going through health centers, including the PONED, the officers or
health centers teams that had been trained by PONED did not have enough confidence to
handle cases that should be able to be handled or at least did first aid before being sent to the
hospital for various reasons. The data was in line with the results of a study from Kismoyo [4]

ISET 2019, June 29, Semarang, Indonesia

Copyright © 2020 EAI
DOI 10.4108/eai.29-6-2019.2290514
that the condition of unavailable doctors in the service area made midwives were not confident
in providing emergency care. the other factor was the unoptimal PONED in reducing MMR
and IMR, also reported from the study of Surahwardy [5], government regulation in PONED
service assistance and monitoring had not been maximized so that the ability of trained
PONED teams could not be used optimally.
In 2014, Health Training Center (Bapelkes) of Semarang has provided training for
PONED health centers team in Central Java. Bapelkes Semarang also has an obligation to
evaluate the effectiveness of the training through post-training evaluation. It is an evaluation
conducted to see how far the changes in mental attitude, improvement of knowledge, and or
the addition of participants' skills have a direct influence on the performance of participants
when returning to their own work environment [6].

2 Method

The mix method data collection was applying concurrent triangulation strategy, mixing
two data when researchers compare one data source with another data source [7]. The
locations of this study were in 10 (ten) health centers which had the alumni of PONED 2014
training participants in Semarang City, Wonogiri, Jepara, Batang, Pekalongan, Brebes, Blora,
Purworejo and Wonosobo Districts. The research was conducted in March to May 2015.
There were 3 (three) evaluation variables. They were the knowledge of respondents after
training; respondents’ attitudes towards PONED training and respondents' skills in applying
the training results. The quantitative data source was the alumni of PONED training
participants that had three people at every health center, with details of doctors, nurses and
midwives. The research sample was based on inclusion criteria.In the end, the researcher
obtained 10 PONED health centers and got the respondents amounted to 30 participants and 2
(two) health centers as respondents to the instrument trial.
The source of the qualitative data was interviewes with the head of the health centers,
colleagues who are involved in the PONED activities, that were the Head of the
Administration Section, Midwives, Nurses, Laboratory and Pharmacy Analysts. The
techniques for collecting quantitative data through questionnaires and knowledge tests while
the qualitative data through interviews with superiors and PONED support teams, the
observation to the training participants alumni, and documents.
The quantitative data were analysed by using SPSS 16.0 with steps to analyze the
numbers descriptively and inferentially to achieve the "first" aim of this study, as follows; to
find out the "effectiveness level" of PONED training using a "training effectiveness"
analytical approach. The stages of data analysis to determine the effectiveness of a training
according to Noe [7] were through several stages, determine the "score" for each respondents’
answer in assessing every aspect of the measurement approach; calculate the "total score" and
the "average score" for each aspect of the measurement approach; calculate "aspect value
(NA)"; and decision making. The technique of analyzing data in the qualitative research
approach was by interpreting the obtained results at the research place with the following
stages of data transcripts; data reduction; presentation of data; and final conclusion.
3 Result and Discussion
3.1 Characteristics of Respondents

There were 22 EPP respondents out of the 24 initial respondents consisting of doctors,
midwives and nurses. The majority of respondents were 86.4% female, and 63.6% were 31-40
years old. The number of bachelors (45.5%) and Diploma (36.4%). The respondents worked
as PONED officers for 1-3 years, which was 45.5%.

3.2 Results of Post Training Evaluation (EPP) for Training Participant Alumni

Post-Training of Respondents’ Knowledge Evaluation. The post test value (88.0) was
higher than the pre test (71.0) during the training, while the value at EPP was slightly lower
than the post test value (79.5). The increase from pre to post test occurred because the
assessment was carried out before and after the training, while the decrease in the EPP post-
test occurred because the length of time from the training was quite long, which was about 1
year.

Respondents' Attitudes in Implementing Training Outcome Skills. The skills that was
often applied was the skill for preparing obstetric-neonatal emergency service, amounted to
96.3% while the skill that lack of application was Stabilization, referral, and transportation of
newborns, as much as 25%. All respondents reported to the Head of health centers and
socialized the results of the training at the workplace to the PONED Support Team. 77.3% of
respondents socialized less than one month after the training, and 81.8% socialized the results
of the training to more than 5 friends at the health centers. Respondents who reported directly
the results of training to the DHO were 59.1%, and the rest were reported to the Head of the
health centers. The training alumni who inventoried and suggested improvements in their
institution in giving addition or improvement of PONED human resources was amounted to
86.4%, 95.5% improvement of PONED facilities and pre facilities, and also system
improvements, procedures related to PONED services was 100%. Respondents who carried
out all the other follow-up plans that had been made during the training were 86.4%.

Skills in Handling Obstetric-Neonatal Cases. The skills of the PONED trainees who were
evaluated in the first indicator were about the mastery of skills in handling the cases that
mostly dominated by respondents (90.9%) were the cases of post partum bleeding and the
cases of hypertension-pre Exlampsia. While the case of hyperbilirunemia was the most less
mastered by respondents (27.3%). The percentage of successful obstetric-neonatal treatment
after the PONED training as a second indicator showed that in each of the PONED in public
health center, most of them were referred. Some cases were unsuccessful and died. The most
referring c was in Brebes Regency as many as 87.1, while the public health center that handled
the most cases was in Pekalongan City as many as 61.2. The third indicator related to the types
of cases that were successfully treated until the patient returned was BBL asphyxia cases
which reached 97%, while the definite cases referred were neonatal infection, hypoglycemia
and hypothermia because these cases were not under the authority of the public health center.
The last indicator evaluated on the PONED of the public health center referral network had
running well, 16.5% of patients were referral from nearby health facilities such as the Midwife
Independent Practice (BPM) and others. In addition to receiving referrals from the
surrounding health facilities, the PONED of public health center also referred back to the
surrounding health facilities and received referrals from the PONEK in Hospital.

Supporting and inhibiting factors for the application of the PONED training results.

Table 1. Policy as Supporting and Inhibiting Factors For The Application of The PONED Training
Results

SUPPORTING FACTORS INHIBITING FACTORS

Determination of the decision letter of the The referral system was not running optimally,
PONED Team and the PONED Support Team. BPJS patients are difficult to be referred.
There was mini public health center workshop. The standard operational of the action already
exists along with the Self Assessment form,
but the revision was done before the
accreditation of the public health center.
Regular meeting forum for traditional birth
attendants (monthly).
The provision of mandatory delivery at the
health center, especially during working hours
Patient referral was accompanied by officers
and stabilized according to Standard
operational.
Increasing the collaboration with visiting to the
center of statistic department (BPS).
Collaborating partners / sectors include the
sub-district, FKD, FRK (Forum for Refreshing
Cadres) which guided by doctors, nurses,
midwives and nutrition workers

Supporting factors for the application of the PONED training results was one component
in achieving success in the implementation of the PONED in public health center. One of
them was by establishing a PONED Decree from the Regent as a legal basis that strengthens
the implementation of PONED. Likewise, about what happened in Brebes district in the
research on the Implementation of the Basic Emergency Obstetric and Neonatal Service
System (PONED) in the Sitanggal Health Center in Brebes Regency had been supported by
the determination of the PONED decision letter from the regent namely the Brebes Regent
Decree Number 050/488 of 2015 concerning Determination the ability of the public health
center as Basic Emergency Obstetrics and Neonatal Services (PONED) in Brebes Regency
and Decree on the determination of the core PONED team from the head of the health service
namely Decree of the Head of Brebes Regency Office Number 800.2 / 8734 Year 2015
Regarding the Establishment of a public health center Implementing Core Team who were
Capable in Obstetrics and Basic Emergency Neonatal Services (PONED) ) [8].
The inhibiting factor in implementing the results of the PONED training for trainees was
the referral system which had not been able to run optimally due to policies that block the
PONED referral system. This condition was not only a problem in Central Java, the Northern
Territory of Aceh Province had also experienced the same problem in terms of the referral
system, human resources and referral targeting facilities to be one of the obstacles in
organizing the success of PONED health center referral to PONEK [9].
Table 2. Human Resources (HR) as Supporting and Inhibiting Factors or The Application of The
PONED Training Results

SUPPORTING FACTORS INHIBITING FACTORS

The PONED Team and the PONED Support Human Resources / Team PONED still lacking.
Team understand enough of the duties and
functions.
Official shift system. Complete morning service, Most of the skills are not applied because there
day and night service of 2 midwives were no cases.
Human Resources Management, The division of Lack of confidence in applying skills, even
the shift was considered in balanced expertise though in theory they understand.

Human Resources were as another supporting component in the implementation of

quality PONED in public health center. The presence of sufficient number of human
resources and a balanced distribution of work shifts determines the quality of services
provided to patients. In line with the results of research at the PONED Oesao Kupang Health
Center that there was a significant influence from the aspect of human resources on the quality
of neonatal services [10]. Adequate and professional human resources determine the success
in saving patients. PONED of public health center in Bandung city was one of the puskesmas
with a "Staffing" indicator that was categorized as weak so there needed to be a review of the
number of staff and workload so that the quality of PONED public health center services
could be optimal [11].
Human Resources competency was also one of the supporting components for the
successful implementation of the post-training PONED health center. The competency of
PONED participant in the Karawang district was not yet sufficient so that some authority was
given in the administration of the PONED health center. This condition becomes one of the
evaluation materials for training providers in determining the next PONED training policy
[12].

Table 3. Infrastructure as Supporting and Inhibiting Factors for The Application of The PONED
Training Results

SUPPORTING FACTORS INHIBITING FACTORS

Medicine was quite complete. The delivery room was in one room with the
puerperium
Operational standard action already exists along Health equipment and medicines: quite
with the Self Assessment (SA) form. complete, but incubators did not yet exist.
Completeness of data: Map of the work area

The availability and adequacy of PONED tools and medicines at the public health center
was also a supporting factor for former PONED trainees in applying the results of the training
in their work environment. This condition was in accordance with the results of the PONED
health center research in the Java-Bali region which was said to have better readiness
compared to other regional health centers in PONED services including thse availability and
adequacy of PONED tools and medicines [13].
3.3 Post-Training Evaluation Results (EPP) of Respondents (Triangulation)

PONED Support Team. The PONED support team consisted of doctors, midwives, nurses,
health analysts, administrative staff and others who were given questionnaires. Data obtained
by 97% of the PONED support teams have received information and 95% of the teams had
worked in accordance with the Standard Operational. The PONED support teams by 61% had
not received decision letters related to PONED and 68% had never gained competency by
apprenticeship at PONED Hospital.

Alumni of the Head of Public Health center. Post training evaluation conducted on alumni
superiors of the public health center obtained data that 83% of public health center had been
used for PONED; the majority of public health center also collaborated across sectors to
support PONED at 63%. Coaching had also been carried out both from the Health Office and
from the district hospital in supporting PONED, the Health Office provides guidance to the
majority of health centers, there were 62% and 41% of hospitals. Cross-sectoral cooperation in
Central Java had a big role in supporting the implementation of PONED in public health
center. The high percentage of cross-sector support was one of the factor for the achievement
of maternal and child mortality in Central Java with the presence of a PONED in public health
center. Not all regions have cross-sector supports, the results of the analysis of the
implementation of the PONED program in Depok City still need to optimize partnerships with
various sectors in an effort to accelerate the reduction of maternal mortality [14]. Support and
participation from cross-sectoral as PONED implementation partners turned out had a big role
in efforts to reduce maternal and child mortality[15].

Public Health Office

Table 4. Public Health Office Result

POLICY GUIDANCE

PONED Public health center decision letter. HR development in the form of

training: umbilical infusion
All birth are performed at the PONED in public health center. The use of equipment that never be
used.s
Every pregnant woman is controlled at least once by a doctor.
Supervision of Obsgyn specialists at once a year in each
district.
Guidance of health centers by the health services at once a
year, Technical guidance by the field of public health
development (Kesga 2 x a year)
Procurement of facilities and infrastructure from the
Department of health and the regional budget
The implementation of PONED uses national-level of
standard operation.
The AMP policy has been carried out since 2010. If there is a
case, an assessment is done by a team consisting of SPOG,
Pediatricians, SPOG doctors, Midwives, Nurses.
 The support and participation of the Health department as a core and controller of the
quality of PONED in public health services is a vital part. The implementation of the PONED
in public health services in Bangetayu had not been fully effective due to the lack of support
from the Health department [16]. Support from the Health department in the form of
improving the quality of human resources, fulfilling infrastructure facilities, giving awards,
assisting and evaluating were one of the success factors of the PONED program at the
designated health centers. The lack of supervision by the Health Office Department for the
PONED program was also still found in Karang Malang Public Health Center Semarang [17].
Most supervision was carried out at the beginning and middle of the semester but not yet
focused on the implementation of the PONED program.

PONEK Hospital. Based on the eight public health center of EPP respondent, only 4 PONEK
hospitals were used as data collection respondents, this was due to various limitations, with
the following results:

Table 5. Public Health Office Result

ADVANTAGES DISADVANTAGES
PONEK in Hospital has become a patient referral The PONED officer does not yet have sufficient
by the PONED in public health center. competence in determining the patients to be
referred and stabilizing the patients so that they
need to be improved
The PONED in public health center refers by Not all PONED in public healths center use
using the appropriate documents but some of PONEK Hospital as a place of internship for
them do not use standard forms yet; accompanied PONED officers to improve their competence.
by a midwife; and before referring,
communication via telephone with the PONEK in
Hospital is a must.
The PONED officer monitors the progress of his
referred patients, by visiting directly or by
telephone to the PONEK Hospital.
The guidance of PONEK in Hospital to PONED
Pin public health center is carried out routinely in
the form of technical guidance by obstetricians
and some pediatricians who come to the public
health center. Some have not been coaching
routinely because there is no clarity of duties /
authority from the District / City Health Office.
A Maternal Perinatal Audit (AMP) is always
carried out in a maternal or infant death,
involving all relevant parties.

4 Conclusion

From the EPP results, it was concluded that the average value of respondents' knowledge
about training material was estimated to be 79.5. The compliance of respondents in applying
the skills of preparation for obstetric-neonatal emergency amounted to 96.3%. Meanwhile,
stabilization, referral, and transportation of newborns was 25%. Skills for handling post
partum hemorrhage cases and cases of Hypertension (Pre) Eclampsia was 90.9%; case of
hyperbilirunemia in the amount of 27.3%.
Supported factors that influenced the implementation of the training results were regular
meetings at the health centers through lokmin activities to discuss PONED cases and guidance
from Public Health Office and RSUD. The inhibiting factors included incomplete facilities
and equipment; lack of staff skills; only few patients that made the staff did not have many
skills that could be practiced in PONED management
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