Chapter 1

Introduction

The United Nations Millennium Summit, held during the 55th session of the United Nations General Assembly in 2000, called for a coordinated global effort to reverse the poverty, hunger, and disease that affect billions of people (United Nations General Assembly, 2000). In 2002 the UN’s secretary-general commissioned the United Nations Millennium Project with an eye toward developing a concrete action plan to achieve certain Millennium Development Goals (MDGs) by 2015. In 2005 a blueprint document, Investing in Development: A Practical Plan to Achieve the Millennium Development Goals, was approved by all member states and the leading development institutions (UN Millennium Project, 2005). The eight MDGs that emerged covered issues related to education, poverty, health, environmental sustainability, and international cooperation, and they were assigned quantitative targets to be achieved by the 2015 deadline. The MDGs were then adopted by nations and international development agencies as benchmarks for improving the human condition. The upcoming deadline of 2015 thus figures heavily in national planning efforts.

The MDGs and Indonesia

The Republic of Indonesia, home to over 240 million people, is the world’s fourth most populous nation. According to the UN Human Development Index (HDI),1 in 2012 Indonesia ranked 121st out of 185 countries in human development. However, over the last 20 years the rate of improvement in Indonesia’s HDI ranking has exceeded the world average. This progress may be attributable in part to the fact that Indonesia has put considerable effort into meeting the MDGs, and especially MDGs 4 and 5, which target maternal and child health. This report is intended to be a contribution toward achieving these two Millennium Development Goals:

MDG Target 4.A: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate, the number of children who die under the age of five per 1,000 live births per year.

MDG Target 5.A: Reduce by three quarters the maternal mortality ratio (MMR). The MMR is defined as the number of women who die during pregnancy and childbirth per 100,000 live births per year.

The definitions of the MDGs raise several methodological and policy issues for researchers and policy makers. Because the baseline is set at 1990, the data from that year should be as accurate as the data to be derived in 2015. Determining whether the MDGs have been achieved may therefore entail improving the reporting rate and precision of the data, which in itself is likely to produce a short-term increase in the ratios because of earlier undercounting, even as more lives were being saved. This possibility is suggested by the fact that figures for Indonesia publicly reported for the under-5 mortality ratio in 1990 ranged from

 

1http://hdr.undp.org/en/statistics/hdi/.



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Chapter 1 Introduction The United Nations Millennium Summit, held during the 55th session of the United Nations General Assembly in 2000, called for a coordinated global effort to reverse the poverty, hunger, and disease that affect billions of people (United Nations General Assembly, 2000). In 2002 the UN’s secretary-general commissioned the United Nations Millennium Project with an eye toward developing a concrete action plan to achieve certain Millennium Development Goals (MDGs) by 2015. In 2005 a blueprint document, Investing in Development: A Practical Plan to Achieve the Millennium Development Goals, was approved by all member states and the leading development institutions (UN Millennium Project, 2005). The eight MDGs that emerged covered issues related to education, poverty, health, environmental sustainability, and international cooperation, and they were assigned quantitative targets to be achieved by the 2015 deadline. The MDGs were then adopted by nations and international development agencies as bench- marks for improving the human condition. The upcoming deadline of 2015 thus figures heavily in nation- al planning efforts. The MDGs and Indonesia The Republic of Indonesia, home to over 240 million people, is the world’s fourth most populous nation. According to the UN Human Development Index (HDI), 1 in 2012 Indonesia ranked 121st out of 185 countries in human development. However, over the last 20 years the rate of improvement in Indone- sia’s HDI ranking has exceeded the world average. This progress may be attributable in part to the fact that Indonesia has put considerable effort into meeting the MDGs, and especially MDGs 4 and 5, which target maternal and child health. This report is intended to be a contribution toward achieving these two Millennium Development Goals: MDG Target 4.A: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate, the number of children who die under the age of five per 1,000 live births per year. MDG Target 5.A: Reduce by three quarters the maternal mortality ratio (MMR). The MMR is defined as the number of women who die during pregnancy and childbirth per 100,000 live births per year. The definitions of the MDGs raise several methodological and policy issues for researchers and pol- icy makers. Because the baseline is set at 1990, the data from that year should be as accurate as the data to be derived in 2015. Determining whether the MDGs have been achieved may therefore entail improving the reporting rate and precision of the data, which in itself is likely to produce a short-term increase in the ratios because of earlier undercounting, even as more lives were being saved. This possibility is suggested by the fact that figures for Indonesia publicly reported for the under-5 mortality ratio in 1990 ranged from 1 http://hdr.undp.org/en/statistics/hdi/. 7

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8 Reducing Maternal and Neonatal Mortality in Indonesia 71 (UN Inter-agency Group for Child Mortality Estimation, IGME) to 86 (Institute for Health Metrics and Evaluation, IHME), and for the maternal mortality ratio from 404 (IHME) to 600 (Maternal Mortality Estimation Interagency Group, MMEIG). The issue of data accuracy is discussed further in Chapter 2 (see Table 2.9). Overall maternal and neonatal mortality depend on two factors, the mortality rates per live births and the number of births, based on population and the fertility rate. Since the late 1960s, Indonesia has seen fertility (as measured by the total fertility rate, TFR) decline by more than 50 percent, from 5.6 to 2.3, based on census and intercensal survey sources. This decline has stemmed in part from the imple- mentation of a vigorous family planning program starting in the mid-1970s and to social and economic change, particularly massive improvements through the 1970s and 1980s in basic education for girls af- fecting the total number of births. The family planning projects of the 1970s and 1980s also saw significant declines in fertility at the youngest and oldest ages and in the shortest birth intervals—conditions that coincide with the highest risk of mortality in childbirth. Those declines alone would have led to a reduction in the mortality rates, but fertility rates have been static since the mid-1990s, and changes in mortality must be attributed in large part to other factors entering into the calculation of mortality ratios. The challenge presented by the MDGs coincides with the focus needed to further reduce the tragic and avoidable loss of life. This is not to minimize, however, the importance of fertility reduction programs; they should be an integral part of the safe childbirth services offered to Indonesian women (see the appendix for more on fertility reduction and family planning). For the policy maker, an interesting aspect is the timing. The United Nations Millennium Summit declaration was issued in 2000, which should have spurred new efforts to meet the MDGs. Consequently, the rate of improvement of the indexes after 2000 may well be assumed to be a measure of the effective- ness of new efforts aimed at meeting the MDGs. However, in Indonesia and some other countries the rate of improvement actually declined after 2000 (see Chapter 2, Figures 2-3A and 2-3B). One reason may be the excessively high maternal mortality estimates in 1990, which were then re- fined in 2000. But, by definition, achievement of the MDGs by 2015 depends directly on the relative pro- gress made since 1990. Agencies whose estimates of maternal mortality and under-5 mortality in 1990 are high tend to report more “progress,” and therefore more probability of achievement of the MDGs by 2015, even where there is little disagreement on the mortality rates in 2010. These realities, the quality of the 1990 data, and their refinement in 2000 all but preclude, then, a meaningful assessment of where In- donesia might be on the road to achieving MDGs 4 and 5. The under-5 mortality rate is attributable to a diversity of causes that affect neonates, infants, and children from ages 1 to 5 in different ways. These causes include maternal and infant nutrition, accidents, childbirth emergencies, and infectious diseases such as malaria. Furthermore, between 1990 and 2010 in Indonesia greater relative progress toward MDG 4 was made for the under-5 and infant mortality rates, which improved by more than 50 percent, than for the neonatal mortality rate (NMR), which improved by less than 40 percent (see Table 2-6 in Chapter 2). The maternal mortality ratio also improved by about 40 percent, according to Indonesian government data. The medical conditions that cause maternal, fetal (stillbirth), and neonatal deaths are often the same. An elevated risk of maternal death implies a high risk of both stillbirth and neonatal death. Thus interven- tions aimed at reducing maternal mortality will frequently reduce stillbirths and many neonatal deaths. Causes of increased maternal, fetal, and neonatal mortality include poor nutrition, living in poverty, poor access to care, and poor quality of care. As noted, the poor quality of care and unsafe conditions that jeopardize the life of the mother are more likely to jeopardize the fetus and newborn as well. In high- income countries, the availability and utilization of the appropriate medical care for mothers and new- borns have in recent decades reduced maternal, fetal, and neonatal mortality each by 90 percent or more and have the potential to do the same in low- and middle-income countries. The joint study committee (described later in this chapter) decided to concentrate in this report on the lagging neonatal mortality rate, together with maternal mortality. Details of the medical causes of maternal and neonatal mortality,

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Introduction 9 both direct (complications of pregnancy and unsafe or inadequate obstetric practices) and indirect (preex- isting or non-obstetric conditions), are presented in Chapter 3. Indonesian Health Care System Despite decades of governmental exhortations and programmatic support, a large number of births in Indonesia still take place at home. Most home births are attended by midwives or traditional birth at- tendants, but they frequently lack the skills and experience needed to save lives in the face of obstetrical emergencies. Patients who require emergency services encounter a hierarchy of community health facili- ties that refer highly complex cases to more capable facilities, thereby losing critical time in the process. Hospitals sometimes defend their poor records of maternal and neonatal fatalities by pointing out that many of the patients needing their services arrive too late to be saved. However, at times these very hospi- tals lack the staff, skills, medicines, or equipment required to save lives. The present Indonesian health system and factors related to choice of birth venue are described in Chapter 4, and quality of care issues are discussed in Chapter 5. Indonesia is an island archipelago. The implications for the timely transport of patients to an emer- gency health facility are therefore self-evident and highly challenging. Maternal and neonatal mortality rates vary widely among Indonesia’s provinces and districts, many of which are sparsely populated and unable to afford rapidly accessible care for the entire population. In this respect, Indonesia may always be at a disadvantage in meeting the MDGs when compared with smaller, more compact countries with more inclusive land communication. Going forward, the Indonesian government will likely face the difficult choice of whether to direct limited resources to highly populated provinces where more lives can be saved, or to sparsely populated—indeed remote—island-rich provinces where higher mortality rates may be the norm. The impact of the geography of Indonesia was brought front and center in 2000 when the Indonesian government introduced decentralization reform that shifted the major responsibility for health care to the district governments. Nearly all purchasing power and staffing that had resided with the central govern- ment were placed in the hands of the roughly 500 districts and municipalities throughout the country. De- centralization has increased the difficulty of establishing coordinated national health programs and ac- counting for health funds. And yet it has provided Indonesia with an opportunity to redress issues of inequity between areas of high and low population density by shifting many health funding decisions to the local level. The consequences of the present system of governance are further described in Chapter 6. Finally, there is the problem of financing and cost. The costs of training health care workers and of supporting hospitals and community health centers are paid through complex financing mechanisms in- volving central government ministries, district governments, and households. A national insurance pro- gram covers childbirth, but it does not yet serve all families. Hospitals complain that the decentralized system requires them to provide services, but with insufficient funds or for inadequate fees. Even families served by public health facilities that should be offering services at no cost find that payment is required, and often the necessary care is delayed. These financing challenges are described in more detail in Chap- ter 7. Finally, the recommendations of the committee are presented and discussed in Chapter 8. The Role of the Science Academies Many agencies and institutions are helping the Indonesian government meet the MDGs. Some of these organizations are international in scope, such as the World Health Organization (WHO), Organisa- tion for Economic Co-operation and Development (OECD), and World Bank. Others are bilateral devel- opment agencies, such as the U.S. Agency for International Development (USAID) and the Australian Agency for International Development (AusAID), or are nongovernmental organizations (NGOs), such as Save the Children. And some are private, such as John Snow International. In addition, researchers from

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10 Reducing Maternal and Neonatal Mortality in Indonesia universities and research organizations, both Indonesian and foreign, are carrying out studies inde- pendently or in collaboration with one of these organizations. These researchers and organizations collect and analyze data, publish papers in peer-reviewed scientific journals, and actively provide resources and services directly to patients and health care facilities in Indonesia. This study is of a different type. The two collaborating organizations are the national science acad- emies of their respective countries. Both are nongovernmental scientific organizations whose members include the most distinguished researchers in the country and, in the case of the U.S. National Academy of Sciences, the world. Both publish peer-reviewed journals, as well as organize and publish the proceed- ings of important scientific meetings. The academies do not carry out original scientific research, but their members are usually best known for the research they conduct at their home institutions. When requested, the academies advise governments and international organizations on science poli- cy issues. This advice usually takes the form of formal published reports, such as this one, that have been prepared by a panel of experts who were selected for their knowledge of and experience in all aspects of the topic, for their independence, and for balance among those with potential biases based on employment or investment. The objective of this report is to provide the best possible recommendations for actions that might be taken to reduce maternal and neonatal mortality in Indonesia. These recommendations are based on the reported information, published data, available evidence, and knowledge gained in the course of the study from patients, families, midwives, government officials, scientists, and health care providers. They are derived by consensus of the authors of the report, identified as the members of the committee. For this reason, the academies refer to a document such as this one as a “consensus report.” When the data are unreliable or contradictory, or when populations, officials, and health providers disagree, a consensus re- port takes all such challenges into account and produces recommendations the committee believes will provide the best guidance available under the circumstances. This joint study was carried out by the Indonesian Academy of Sciences (AIPI) and the U.S. Na- tional Academy of Sciences (NAS)—see the description on page iii of AIPI and of the three academies that compose the U.S. National Academies, together with the National Research Council, its operating arm for consensus studies. The National Academies of the United States have a mandate to serve as “Ad- visors to the Nation on Science, Engineering, and Medicine.” In this context, the National Academies publish about 250 study reports a year, nearly all financed by the U.S. government. A volunteer commit- tee of experts selected by the Academies for the task at hand authors each consensus study. The members of the committee, who are approved by the president of NAS, are assisted by experienced, PhD-level staff. The draft report is reviewed by a different group of experts. The study committee is required to re- spond to all of the revisions suggested by the reviewers, although not necessarily to accept them (see the Acknowledgments section for the reviewers of this study). The resulting publications are widely respected and frequently serve as guides to action by Congress and the White House. Similarly, AIPI has access to the best scientific experts in Indonesia. During the course of this study, AIPI staff underwent training in producing consensus studies with National Academies staff in Jakarta and Washington. Statement of Task The statement of task adopted by the committee was as follows: The United States National Research Council and the Indonesian Academy of Sciences will together form an expert study committee that will carry out the following tasks: 1. Compile and evaluate the quality and consistency of existing data relating to maternal and neona- tal mortality. This will include time and space incidence of fatalities, causes of death, interven- tions implemented, their coverage and effectiveness, and identification of gaps.

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Introduction 11 2. Devise a strategy utilizing evidence-based decision-making to achieve the Millennium Develop- ment Goals relating to maternal, neonatal mortality, and stillbirth in Indonesia. Elements of the strategy may include facilities, technologies, human resources, finances, and quality assurance. 3. Identify the highest priority interventions and propose steps toward development of an effective implementation plan. 4. Use the study process and a special internship to train the staff of the Indonesian Academy of Sciences to enable it to independently carry out similar science policy studies in the future. An expert will design and assist staff to use a project accounting system for donor funded projects. The resulting report will be externally reviewed in accordance with the procedures of the National Academies’ Report Review Committee, and published in English and Indonesian. Once the report is pub- lished, members of the committee will be available to discuss the recommendations in public forums and to brief public officials. Methodology The full joint committee met in person three times, twice in Jakarta and once in Washington, and al- so convened via teleconferencing. Members met as well in smaller groups. During the full joint commit- tee meetings, members heard presentations from Indonesian government officials, health service provid- ers, academic experts, and representatives of international agencies and NGOs (see the Acknowledgments section for a list of the outside participants in the committee meetings). These presentations permitted the joint committee to hear the views of those responsible for the formulation and implementation of gov- ernment policy and their international partners. The joint committee also visited hospitals and community health centers near Jakarta and Makassar, and spoke with patients, doctors, and midwives in order to learn more about the experiences of patients and providers. In addition, joint committee members and consultants reviewed and evaluated the existing evidence, current knowledge, experience of other countries, published survey results, and other data. The committee also took into account the activities of other organizations working in Indonesia and their reports and rec- ommendations for future action. No primary data were collected for this study. Recommendations The eight recommendations of the joint committee appear in full in Chapter 8. (Other chapters in- clude technical recommendations that seek to improve specific operational aspects of maternity and birth services.) In the joint committee’s recommendations, maternal and neonatal care are treated together— situations unsafe for the mother put the newborn at risk, and actions to protect the mother’s life will nor- mally protect the infant as well. The recommendations fall into three categories: (1) accessibility to health care facilities; (2) improvements in the system of health care for pregnancy and delivery in Indonesia; and (3) the broader issues of an expanded role for existing women’s volunteer organizations and district health departments and stronger programs for the education and empowerment of girls. References United Nations General Assembly. 2000. United Nations Millennium Summit Declaration. Available at http://www.un.org/millennium/declaration/ares552e.htm. UN Millennium Project. 2005. Investing in Development: A Practical Plan to Achieve the Millennium Development Goals. Overview. New York: United Nations.

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