ABSTRAKRumah sakit Umum Daerah Tipe C sebagai Pusat Rujukan di Kabupaten mempunyai peranan penting dalam program penurunan angka kematian ibu dan anak di daerahnya. Demikian juga Rumah Sakit Umum Subang di Jawa Barat yang berpenduduk 1,3 juta orang mempunyai dua dokter spesialis kebidanan dan dua spesialis anak dengan sepuluh orang bidan, melayani rujukan yang berasal dari dokter, Puskesmas, Bidan maupun dukun bayi.Sampai dengan saat ini kegiatan pelayanan rujukan tersebut belum pernah dievaluasi.Penelitian ini bertujuan untuk mengkaji aktivitas pelayanan kesehatan ibu dan anak di kabupaten Subang dengan berfokus pada aktivitas rujukan medis dalam serial waktu 1989-1996 dengan menilai proses yang terjadi selama delapan tahun dan hasil yang tercatat. Data dikumpulkan melalui catatan medis dalam sistem rujukan.Pada analisis terlihat perbedaan yang mencolok terjadi pada tahun 1993, dimana terjadi kenaikan sebanyak 33-43 % kasus-kasus rujukan maternal maupun perinatal. Sejalan dengan itu angka bedah Caesar meningkat 11% setiap tahunnya dan rujukan partus normal menurun. Angka kematian perinatal meningkat terutama pada kasus yang dirawat kurang dan 48 jam pertarna dengan sebab kematian asfiksia dan Berat Badan Lahir Rendah. Pada kasus ini dengan jumlah kasus yang meningkat tidak diimbangi dengan kelengkapan pelayanan intensif perinatal, sehingga banyak kasus yang tidak dapat ditolong. Rujukan kasus kehamilan resiko tinggi meningkat dan sebab kematian maternal ialah perdarahan dan eklamsi.Selama delapan tahun dilakukan sekitar 9 bentuk interfensi yang dilakukan oleh Rumah Sakit Umum Subang bersama Dinas Kesehatan Kabupaten Daerah Tingkat II Subang, antara lain pembentukan Puskesmas dengan perawatan, penempatan bidan desa, menyediakan ruang perinatologi di rumah sakit, membentuk Tim Rujukan rumah sakit, ceramah di organisasi IDI dan IBI, pelatihan tenaga kesehatan dan pelatihan dukun bayi.Banyak spesialis kebidanan maupun spesialis anak di daerah enggan terjun ke daerah, kami menyarankan kepada Departemen Kesehatan untuk membuat suatu posisi tertentu bagi para spesialis sehingga mereka mau tidak mau terjun dalam program kesehatan di daerah melalui suatu Surat Keputusan resmi. Penelitian ini juga mengusulkan kepada rumah sakit untuk melengkapi dengan unit pelayanan intensif perinatal/neonatal. Diperlukan juga peningkatan partisipasi dari lintas sektoral untuk mendukung kegiatan rujukan ini terutama bagi kaum yang tidak mampu.Daftar bacaan : 24 buah

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ABSTRACT

Referral System of Maternal and Child Health Analysis. A Studi Case in General Hospital of Subang District in 1989-1996.

Set up as a medical referral for complicated maternal and child cases, a district hospital in Indonesia plays a huge role in its contribution to decrease infant and maternal death in its catchman area. Subang District Hospital is one of it. Lies in hilly Subang District in West Java province, serves 1,3 million population. It has run maternal and child health care since its establishment in 1984, given at the obgyn outpatient and inpatient service, which is staffed by 2 obgyn, 2 pediatrician and 10 clinical midwives. Complicated cases have been referred so far, either a self referral or sent by the traditional birth attendants, or by the health center doctors and midwives.

It is felt nowadays that Subang Hospital has made a sufficient contribution toward the improvement of MCH program in Subang district, however, these activities renders by the hospital has never been evaluated. Therefore, no empirical data could be shown sa far to evident the contribution, moreever, no lesson learned or successful stories could be disseminated. This study aimed to evaluate the maternal- and child health activities conducted by Subang Hospital, focusing on its activities related to the medical referral system, using a 8 years time series data from 1989 to 1996 , to assess the process accrued during those years in order to achieve outputs recorded. The data was collected through the medical records to this referral system activities.

The analysis showed that differences in output achievements started to occur after 1993,.where in that year high risk Maternal and Prenatal cases referred to the hospital increase sharply to 33-43% per year afterwards. Commensurating to that, number of sectio caesarians conducted in the hospital increases 11% every year, and normal deliveries decreased. Neonatal death after the first 48 hours of hospitalization increase since 1993, with main causes are neonatal asphyxia and low birth weight. In this case, number of cases increase, but the hospital is not equipped with a neonatal emergency room, which made the hospital failed in surviving those little souls. High risk pregnancy cases referred increases, and main cause of deaths are severe bleeding predisposed by heavy anemia and eclampsia.

During those 8 years 9 kind of interventions have been conducted in the hospital setting. Those were; the formal establishment of the AMP team, the deployment of new young fresh graduates midwives in each village in Subang district, intensive maternal and child care education to the community through the health eadres and community midwives, knowledge and eithiocal backup by midwives and physicians's proffesional organizations, continous trainning to the traditional birth attendants, and emergency obgyn care and treatment trainings for the community midwives.

The study recommends to the Department of Health to respect the obgyns and pediatrician who are also dedicate their work by serving community outside the hospital setting through issuing a legal acknowledgement (Letter of Decree). This is because most obgyns and pediatricians only focus their work and job at their station, hospital, and only a few of them are willing to serve in the community setting. The hospital also pleas for the provision of emergency prenatal care unit, since the need is obvious. Increase participation and contribution from other related sectors as well as from the community to back up transportation fee for those low socioeconomic high risk cases (mothers and or infants) which have to be referred to the hospital for survival is very much expected. The Medical trainings for community midwives are urged to be continued and training should be given in the hospital in an internship setting.

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