REDUCING

Maternal and Neonatal

MORTALITY IN INDONESIA

Saving Lives, Saving the Future

Joint Committee on Reducing Maternal and Neonatal Mortality
in Indonesia

Development, Security, and Cooperation
Policy and Global Affairs

NATIONAL RESEARCH COUNCIL
                       OF THE NATIONAL ACADEMIES

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Joint Committee on Reducing Maternal and Neonatal Mortality in Indonesia Development, Security, and Cooperation Policy and Global Affairs

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 10000242 between the National Academy of Sciences and the United States Agency for International Development. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the sponsors who provided support for the project. International Standard Book Number-13: 978-0-309-29076-0 International Standard Book Number-10: 0-309-29076-7 Limited copies are available from Development, Security, and Cooperation, National Research Council, 500 Fifth Street, NW, Washington, DC 20001; 202-334-3840. Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2013 by the National Academy of Sciences. All rights reserved. Printed in the United States of America.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars en- gaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sci- ences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal govern- ment. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the pub- lic. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional char- ter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, re- search, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the fed- eral government. Functioning in accordance with general policies determined by the Academy, the Council has be- come the principal operating agency of both the National Academy of Sciences and the National Academy of Engi- neering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org The Indonesian Academy of Sciences (AIPI) was established in 1990 under the Republic of Indonesia Law No. 8/1990 on the Indonesian Academy of Sciences. The Academy was created as an independent body to provide opin- ions, suggestions, and advice to the government and public on the acquisition, development and application of sci- ence and technology. It is organized into five commissions dealing with Basic Sciences, Medical Sciences, Engi- neering Sciences, Social Sciences, and Culture. It seeks to promote science through scientific conferences and policy discussion forums, publications, furthering national and international relations, and other activities. Prof. Sangkot Marzuki is president of the Indonesian Academy of Sciences.

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JOINT COMMITTEE ON REDUCING MATERNAL AND NEONATAL MORTALITY ELI ADASHI (Co-chair), Professor of Medical Science, The Warren Alpert Medical School, Brown University; Member, U.S. Institute of Medicine MAYLING OEY-GARDINER (Co-chair), Professor, Faculty of Economics, University of Indonesia; Member, Indonesian Academy of Sciences GEORGE ADRIAANSZ, Chairman, Indonesian National Clinical Training Network; Maternal Health Training Adviser (Consultant), Directorate General of Medical Services, Ministry of Health, Republic of Indonesia PETER BERMAN, Professor of the Practice of Global Health Systems and Economics, Department of Global Health and Population, Harvard University School of Public Health ROBERT L. GOLDENBERG, Professor, Columbia University Medical Center; Member, U.S. Institute of Medicine SUDIGDO SASTROASMORO, Professor, University of Indonesia ANURAJ SHANKAR, Senior Research Scientist, Department of Nutrition, Harvard University School of Public Health SOEHARSONO SOEMANTRI, Independent Consultant; Member, Indonesian Community Statistics Forum Staff MICHAEL GREENE (Co-Study Director), Division of Policy and Global Affairs, National Research Council RIANA NUGRAHANI (Co-Study Director), Indonesian Academy of Sciences USWATUL CHABIBAH, Editor, Indonesian Academy of Sciences BARNEY COHEN, Director, Committee on Population, Division of Behavioral and Social Sciences and Education, National Research Council* ROBERT GASIOR, Program Associate, Division of Policy and Global Affairs, National Research Council GEMA JUNITA, Indonesian Academy of Sciences ELFITA SINAGA, Indonesian Academy of Sciences Consultants ROOSYANA HASBULLAH, Researcher, PT Kalta Bina Insani, Jakarta MOHAMAD IBRAHIM (BRAM) BROOKS, Boston University PETER GARDINER, PT Insan Hitawasana Sejahtera (IHS) *Until July 2012 v

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Preface The idea for a joint study by the U.S. National Academy of Sciences (NAS) and the Indonesian Academy of Sciences (AIPI) emerged from a series of discussions held in 2010 between Sangkot Marzuki, president of AIPI, and Bruce Alberts, former NAS president, who was visiting Indonesia in his capacity as a science envoy to the Muslim world on behalf of U.S. President Barack Obama. They were seeking ways in which the United States, through its aid arm, the U.S. Agency for International Development, could assist AIPI in developing its capacity to undertake quality scientific study of key issues and to provide sound, unbiased advice to the Indo- nesian government. It was decided fairly early on to focus on issues surrounding achievement of the UN Millennium Devel- opment Goals (MDGs), and particularly goals 4 and 5 dealing with maternal and infant and child mortality. Maternal mortality reduction (goal 5) was viewed as an especially important concern because it is one area in which performance has been seen by many to be lagging and where the existing programs have not appeared to be having the desired effects. The performance in reducing infant and child mortality has been judged to be considerably better, but less than adequate results have been achieved in child deaths related to and just after birth (neonatal mortality). Because of the close relationship between neonatal mortality and the other issues surrounding childbirth, it was decided to include this problem as well. These decisions meant that there could be two tangible benefits for AIPI from cooperation: first, the abil- ity to provide the Indonesian government with sound policy advice on an important topic and, second, an op- portunity to build the capacity of AIPI to develop and mount, on its own, major policy studies meeting interna- tional quality standards. This cooperative effort has depended on the roles played by the study cochairs and by the joint study committee. Members of the committee, with substantive contributions from both Indonesian and U.S. experts, not only prepared the substantive material contained in the report, but also participated in various meetings to plan the scope of the work, refine the draft chapters, and compile the specific recommendations that appear at the end of the report. AIPI also benefited from opportunities to recruit and train two research staff members who were funded under the project. Although, in accordance with NAS practice, the study did not include any primary research, it was able to draw on a range of expertise in areas such as health statistics, the causes and prevention of maternal mortali- ty, organization of health systems and functions, health service delivery and quality of care, governance issues, and health finance. The joint nature of the study committee also ensured a strong international comparative perspective, along with more detailed knowledge of specific aspects of the Indonesian experience. Because of the specific targets expressed in the MDGs, a major finding of this study is the lack of cer- tainty (even within a fairly wide margin of error) of exactly what has happened to maternal mortality in Indo- nesia over the last few decades. In the absence of an adequate vital registration system, the various survey- based estimates differ so widely and often have such large margins of error that it is virtually impossible to determine exactly where the country was in the base year of 1990 and where it is today. Short of saying that maternal mortality has almost certainly declined because of lower numbers of higher-risk births as a result of family planning and improvements in prenatal screening and birth attendance, any definitive statement on the extent of that decline cannot be made. The results and recommendations therefore tend to focus on the known successful interventions needed to bring maternal and neonatal mortality down to levels consistent with those in more developed countries and to help provide a framework for action by the Indonesian government. Key is ensuring that the maximum pos- sible proportion of births occur in facilities with comprehensive health care delivery facilities, including access to skilled birth attendants and adequate emergency obstetric care. This is a long-term goal in a country as vast and varied as Indonesia, but one that needs to remain at the forefront of strategic planning. Moreover, it must be accompanied by concerted efforts to improve the overall organization and management of the health care vii

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viii Preface system and service delivery, the training and distribution of the relevant personnel, the collection and applica- tion of health information, and the setting of priorities in health finance. The MDGs have clearly helped to establish objectives and targets for all countries in improving the lives and welfare of their people, and Indonesia is no exception. Although there is still clearly a way to go, we do hope that this study makes a contribution to Indonesia in its efforts to reduce maternal and neonatal mortality to acceptable levels and serves to demonstrate the benefits that can be obtained from this kind of collaborative work between the science academies of the United States and Indonesia. Eli Adashi and Mayling Oey-Gardiner, Co-chairs Joint Committee on Reducing Maternal and Neonatal Mortality in Indonesia of the U.S. National Academy of Sciences and the Indonesian Academy of Sciences

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Acknowledgments The joint committee would like to thank the U.S. Agency for International Development (USAID) for its financial and other support for the study. We would also like to thank the experts in Indonesia and the United States who provided valuable information and advice to the committee during its formal and informal meet- ings. They did not contribute directly to the report and are not responsible for the facts or conclusions present- ed here. These experts were Endang L. Achadi, University of Indonesia; Atmarita, Ministry of Health; Massee Bateman, USAID; Rafael Cortez, World Bank; Harvey Fineberg, president, U.S. Institute of Medicine; Hadiat, Ministry of Planning; Anne Hyre, Jhpiego, Johns Hopkins University; Babay Jastantri, Ministry of Women’s Empowerment and Child Protection; Ardiani Khrisna M, PLAN Indonesia; Marge Koblinksy, USAID; Soewarta Kosen, Ministry of Health; Henry Mosley, Johns Hopkins University; Emi Nurjasmi, Indonesian Midwives’ Association; John Lundine, Save the Children, Indonesia; Riskiyana S. Putra, Ministry of Health; Rachmat Sentika, Coordinating Ministry for People's Welfare; Mary Ellen Stanton, USAID; Surya Chandra Surapaty, member of Parliament of Indonesia; Trihono, Ministry of Health; and Wendy Hartanto, National Population and Family Planning Coordinating Board. And we are grateful to consultants Roosyana Hasbullah, PT Kalta Bina Insani, and Mohamad Ibrahim Brooks, Boston University, for their contributions to the chapter on financing maternal and neonatal health. Peter Gardiner of PT Insan Hitawasana Sejahtera contributed an appendix on fertility reduction. Dillon Zufri, University of Indonesia, prepared the population map of Indone- sia. The study directors—Michael Greene and Riana Nugrahani—provided essential logistical support for the committee and valuable contributions during the deliberations and the drafting of the report. Project consultant Sabra Bissette Ledent ably edited the English-language report issued by the National Research Council (NRC), and Uswatul Chabibah edited the version in Indonesian. This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Academies’ Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institu- tional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report: Mickey Chopra, UNICEF; Jennifer Dohrn, Columbia University; Elena Fuentes-Afflick, University of California, San Francisco; Tjahjono Gondhowiardjo, Jakarta Eye Center Corporate; Wendy Hartanto, National Population and Family Planning Agency; Soewarta Kosen, National Institute of Health Research and Development, Jakarta; Henry Mosley, Johns Hopkins University; Rulina Suradi, University of Indonesia; Norman Waitzman, University of Utah; and Broto Wasisto, Atma Jaya University. Although the reviewers just listed provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Eileen Kennedy, Tufts University, and Elaine Larson, Co- lumbia University. Appointed by the National Academies, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. ix

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Contents ACRONYMS AND ABBREVIATIONS ............................................................................................. xv SUMMARY ........................................................................................................................................... 1 1 Introduction .............................................................................................................................. 7 2 The Data Conundrum ............................................................................................................. 13 3 Maternal, Fetal, and Neonatal Mortality ............................................................................... 27 4 The Indonesian Health Care System ...................................................................................... 39 5 The Quality of Care ................................................................................................................ 53 6 Governance Issues................................................................................................................... 65 7 Strengthening the Financing of Maternal and Neonatal Health............................................ 75 8 Recommendations ................................................................................................................... 91 Appendix Fertility Decline in Indonesia and Its Relationship to Maternal Mortality .................... 101 Glossary ............................................................................................................................................. 109 TABLES, FIGURES, AND BOXES Tables 2-1 Estimated Maternal Mortality Ratio, Indonesia: IDHS, 1994-2012, 15 2-2 MMEIG versus IHME Estimates of Maternal Mortality Ratio: Indonesia, 1990-2010, 16 2-3 Direct Estimates of Number of Maternal Deaths, Maternal Mortality Rate, and Maternal Mortality Ratio by Region: Indonesia, 2010 Population Census, 16 2-4 Model-Based Estimates of Maternal Mortality Ratio, Number of Maternal Deaths, and Annual Reduction Rate: Indonesia, 1990-2011, 17 2-5 Direct Estimates of Childhood Mortality and Percentage Contribution of Neonatal Mortality Rate to Infant Mortality Rate and Under-5 Mortality Rate, Indonesia: IDHS, 1991-2012, 17 2-6 Model-Based Estimates of Childhood Mortality Rates, Indonesia: Number of Under-5 Deaths and Annual Reduction Rate, 21 xi

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xii Contents 2-7 Model-Based Estimates of Under-5 and Infant Mortality Rate, and Annual Reduction Rate, Indonesia, 21 2-8 Percentage of Maternal Deaths by Underlying Cause (ICD-10) in Five Regions of Indonesia: 2010 Population Census, 21 2-9 Trends for Maternal Mortality Ratio and Neonatal, Infant, and Under-5 Mortality Rates, Based on Model (MMEIG and IHME) versus Direct Estimate (IDHS/PC), Indonesia, 23 2-10 Estimates of Maternal Mortality Ratio and Number of Maternal Deaths by Country in ASEAN Region, 2010, 23 2-11 Country Progress toward Millennium Development Goals 4 and 5, Indonesia, 24 3-1 Components of Basic and Comprehensive Obstetric Care, 34 3-2 Major Killers of Mothers, Fetuses, and Newborns in Low-Income Countries, 36 4-1 Health Facilities at Different Levels of Service Delivery, Indonesia, 41 4-2 Signal Functions for Emergency Obstetric and Newborn Care, 43 4-3 Readiness of Public Hospitals to Provide Comprehensive Emergency Obstetric and Newborn Care (CEmONC), 43 4-4 Number of Health Providers and Facilities per 100,000 Population and per 1,000 Square Kilometers, Indonesia, 47 4-5 Percent Distribution of Live Births in the Five Years Preceding the IDHS by Place of Delivery and Place of Residence, Indonesia: IDHS, 2002, 2007, 2012, 48 4-6 Percent Distribution of Live Births in the Five Years Preceding the IDHS by Type of Assistance at Birth and Place of Residence, Indonesia: IDHS, 2002, 2007, 2012, 49 4-7 Percent Distribution of Live Births in the Five Years Preceding the IDHS by Antenatal Care Provider during Pregnancy for the Most Recent Birth and Place of Residence, Indonesia: IDHS, 2002, 2007, 2012, 49 6-1 Percent Distribution of Place of Birth by Education of Mothers and Welfare Quintile: Indonesia, 2007, 67 6-2 Percent Distribution of Live Births during Five Years Prior to 2007 Survey by Place of Birth and Province, Indonesia, 70 6-3 Current District/Municipality Health Services Subjected to Minimum Service Standards in Ministry of Health Regulation No. 741, 2008, Indonesia (targets for percentage of coverage, 2010 and 2015), 71 7-1 Examples of Maternal and Neonatal Health-Related Activities in Different Parts of the Budget of the Ministry of Health: Indonesia, 2010 (U.S. dollars), 80 7-2 Health Insurance Programs: Indonesia, 2013, 81 A-1 Estimated Age-Specific Fertility Rate (ASFR) and Total Fertility Rate (TFR) per 1,000 Women by Age Group and Source of Data, Indonesia, 102 A-2 Estimated Age-Specific Fertility Rate (ASFR) and Total Fertility Rate (TFR) per 1,000 Women by Age Group and Source of Data, Indonesia, 103 A-3 Percent Distribution of Non-First Births in the Five Years Preceding IDHS by Number of Months since Previous Birth, Indonesia: IDHS, 1991-2012, 104 A-4 Percent Distribution of Births by Length of Actual Birth Intervals, Selected Countries in South and Southeast Asia: Most Recent Demographic and Health Survey, 104 A-5 Percent Distribution of Births by Length of Preferred Birth Intervals, Selected Countries in South and Southeast Asia: Most Recent Demographic and Health Survey, 104 A-6 Percent Distribution of All Women and Currently Married Women by Number of Children Ever Born and Mean Number of Children Ever Born, Indonesia: IDHS, 1991-2012, 105 A-7 Percentage of Currently Married Women Having Unmet and Met Needs for Family Planning and Total Demand for Family Planning, Indonesia: IDHS, 1991-2012, 106 A-8 Percent Distribution of Births in the Five Years Preceding IDHS (Including Current Pregnancies) by Fertility Planning Status, Indonesia: IDHS, 1991-2012, 107

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Contents xiii A-9 Total Wanted Fertility Rate and Total Fertility Rate in the Three Years Preceding IDHS, Indonesia: IDHS, 1991-2012, 107 A-10 Need for Birth Spacing, Selected Countries in South and Southeast Asia: Most Recent Demographic and Health Survey, 107 Figures 2-1 Direct Estimates of Neonatal, Infant, and Under-5 Mortality Rates, Indonesia: IDHS, 1991-2012, 18 2-2 Percentage Contribution of Neonatal Deaths to Infant and Under-5 Deaths, Indonesia: IDHS, 1991-2012, 18 2-3 Change in Trends of Neonatal Mortality Rate (A), Infant Mortality Rate (B), and Under-5 Mortality Rate (C) by Time Period, Indonesia: IDHS, 1991-2012, 19 2-4 Comparison of Neonatal Mortality Rate (A), Infant Mortality Rate (B), and Under-5 Mortality Rate (C), Indonesia: IDHS, Selected Years, 20 2-5A Maternal Mortality Ratio: Country Progress, Southeast Asia, 24 2-5B Under-5 Mortality Rate: Country Progress, Southeast Asia, 24 3-1 Main Causes of Maternal Mortality, 28 3-2 Main Causes of Fetal Mortality, 28 3-3 Causes of 3.6 Million Neonatal Deaths, 192 Countries, Based on Cause-Specific Mortality Data and Multi-cause Modeled Estimates, 29 3-4 Maternal Mortality Ratios: United States, United Kingdom, and Sweden, 1900-2000, 29 3-5 Maternal Mortality Ratio per 100,000 Live Births over Time and Interventions that Contributed to Decline, United States, 29 3-6 Long-Term Trends for Stillbirth Rates in 11 High-Income Countries, 1750-2000, 30 3-7 Various Interventions Appropriate to Reduce Maternal, Fetal, and Neonatal Mortality, with Estimates of Number of Lives Saved by 2015 at Full (99 Percent) Coverage by Package, 35 5-1 Birth Attendants at Delivery: Indonesia, 2010, 59 6-1 Number of Civil Servants by Level of Government: Indonesia, 2003-2010, 67 7-1 Per Capita Expenditure on Health: Indonesia, 1995-2010 (constant 2010 U.S. dollars), 76 7-2 Overview of Government Health Resource Flows, Indonesia, 77 7-3 Percentage of Households with Health Insurance by Type: Indonesia, 2009, 82 7-4 Overview of Private Health Resource Flows, Indonesia, 85 7-5 Mean Expenditure for Different Types of Obstetric Care in Government Hospitals in Banten Province, 2006 (U.S. dollars), 87 Boxes 4-1 Indonesian Health Care Facilities: Health Posts, Health Centers, and Hospitals, 42 4-2 The Case of Baby Dera, 43 6-1 Decentralization and Argentina, 69

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Acronyms and Abbreviations ASFR age-specific fertility rate ARR annual reduction rate ASEAN Association of Southeast Asian Nations AusAID Australian Agency for International Development BEmONC basic emergency obstetric and newborn care BPS Statistics Indonesia (Badan Pusat Statistik) CEmONC comprehensive emergency obstetric and newborn care CPM Certified Professional Midwife CRVS civil registration and vital statistics DHS demographic and health survey GFR general fertility rate HDI UN Human Development Index HIS health information system ICD International Classification of Diseases IDHS Indonesia Demographic and Health Survey IGME UN Inter-agency Group for Child Mortality Estimation IHME Institute for Health Metrics and Evaluation IMPRSSP Indonesia Mortality Registration System Strengthening Project IMR infant mortality rate KARS Hospital Accreditation Commission (Komisi Akreditasi Rumah Sakit) LTR lifetime risk MCH maternal and child health MDG Millennium Development Goal MMEIG Maternal Mortality Estimation Interagency Group MMR maternal mortality ratio MNCH maternal, newborn, and child health MNH maternal and neonatal health MSS minimum service standard MoH Ministry of Health (Depkes Departemen Kesehatan) NCTN National Clinical Training Network (Jaringan Nasional Pelatihan Klinis) NHA national health account NHHS National Household Health Survey NHS National Health Survey (Surkesnas) NIHRD National Institute of Health Research and Development (Indonesia) NMR neonatal mortality rate NSES National Socio Economic Survey (Susenas) ob-gyn obstetrics and gynecology Rp rupiah SBA skilled birth attendant TBA traditional birth attendant xv

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xvi Acronyms and Abbreviations TFR total fertility rate U5MR under-5 mortality rate UNFPA United Nations Population Fund USAID U.S. Agency for International Development WHO World Health Organization

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SOURCE: Dillon Zufri, adapted from http://siput.web.id/peta-buta-indonesia-degan-batas- provinsi/.

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