said, a brief review of the history of fertility control in Indonesia appears in the appendix to this report, and the desirability of continued support for family planning and prevention of unwanted pregnancies is included in the recommendations.

The under-5 mortality rate has three components: newborns (neonates), infants (< 1 year), and children 1–5 years of age. The clinical events that undergird maternal, fetal (stillbirth), and neonatal deaths are often the same and as such are closely linked—that is, increased risk of maternal death implies a high risk of both stillbirth and neonatal death. It follows, then, that interventions aimed at reducing the incidence of maternal mortality will also reduce the prevalence of stillbirths and of neonatal deaths. Common determinants of maternal, fetal, and neonatal mortality include but are not limited to poor access to care, the poor quality of that care, the lack of education of many women, and living in poverty. Older infants up to 5 years of age are also affected by malnutrition and infectious diseases such as malaria. Nevertheless, in Indonesia the mortality rate for older infants has improved faster than that for mothers and neonates. Given that constellation, the joint committee convened by the U.S. and Indonesian academies of sciences for this study resolved to focus on the complex of problems afflicting mothers and newborns.

Mortality rates at childbirth are also affected by the levels and age patterns of fertility. In Indonesia, a vigorous national family planning program coupled with social change (particularly in the promotion of basic education for girls) saw fertility as measured by the total fertility rate (TFR) decline by more than 50 percent from the late 1960s to the early 2000s, with the TFR reaching a level of 2.6 by 2002, according to the Indonesia Demographic and Health Survey (IDHS). This overall decline has included major declines in fertility among women at higher-risk ages, particularly those in their teens and over 40, as well as marked increases in the average intervals between births.

With little recorded change in fertility rates since 2000 and a consistent gap in the unmet need for contraception as measured by the 2007 and 2012 IDHS, there is scope for further declines in fertility that would likely have a positive impact on maternal health. These declines should be encouraged through a reinvigorated family planning program that would be an integral part of the safe childbirth services offered to Indonesian women.

The current Indonesian programs directed at reducing maternal and neonatal mortality have proven insufficient to meet the MDG targets, according to the commonly accepted data sources. Many of the actions needed must be implemented locally, in or near where people live. Because maternal and neonatal mortality and some of their major determinants vary considerably among districts and municipalities, designing locally appropriate solutions is all important for program success. One striking example is the disparity in mortality rates between the more densely populated areas of the country and those that are more sparsely populated and thus face far more substantial transport and communications challenges. Life-saving programs are generally more cost-effective where population density, personal wealth, and quality of facilities are highest, but cost-effectiveness and absolute impact must be balanced against equity in a country as geographically diverse as Indonesia. Moreover, in 2001 Indonesia adopted a decentralization policy that shifted political and budgetary power to the districts and municipalities, and so most decisions are now made at that level, which further increases the need for locally feasible and acceptable strategies.

In 1989 the Indonesian government launched a Midwifery Education Rapid Training Program to increase access to basic midwifery services in the villages. By 1998 this initiative had led to the establishment of midwifery academies with a three-year curriculum. The National Education System that followed in 2003 transferred all sectoral education programs, including health education, to the Ministry of Education. This resulted in a 15-fold increase in the number of midwifery academies. Concurrently, the number of midwives increased from 52,000 in 2006 to over 200,000 in 2012. This number of trainees exceeds the capacity of any academy to offer adequate hands-on childbirth training experience in the face of a relatively stable national birth cohort. Also, many of the midwives constituting the current workforce are products of the earlier one-year course that offered little in the way of hands-on experience with childbirth emergencies. Moreover, many of the village-bound midwives are relocating to the cities in search of patients, thereby diluting their presence in underserved rural districts. With recent statistics indicating the country’s inability to effectively reduce its maternal mortality rate, the large midwife contin-



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