National Academies Press: OpenBook
Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
×

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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THE NATIONAL ACADEMIES PRESS

Washington, D.C.

www.nap.edu

Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
×

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.

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Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged 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 Sciences, 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 government. 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 public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, 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 federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering 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

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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 opinions, suggestions, and advice to the government and public on the acquisition, development and application of science and technology. It is organized into five commissions dealing with Basic Sciences, Medical Sciences, Engineering 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.

Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
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Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
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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

Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
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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 Indonesian government.

It was decided fairly early on to focus on issues surrounding achievement of the UN Millennium Development 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 ability to provide the Indonesian government with sound policy advice on an important topic and, second, an opportunity to build the capacity of AIPI to develop and mount, on its own, major policy studies meeting international 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 mortality, 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 certainty (even within a fairly wide margin of error) of exactly what has happened to maternal mortality in Indonesia 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 possible 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

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Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
×

system and service delivery, the training and distribution of the relevant personnel, the collection and application 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

Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
×

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 meetings. They did not contribute directly to the report and are not responsible for the facts or conclusions presented 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 Indonesia. 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 institutional 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, Columbia 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.

Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
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Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
×

2-7         Model-Based Estimates of Under-5 and Infant Mortality Rate, and Annual Reduction Rate, Indonesia

2-8         Percentage of Maternal Deaths by Underlying Cause (ICD-10) in Five Regions of Indonesia: 2010 Population Census

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

2-10       Estimates of Maternal Mortality Ratio and Number of Maternal Deaths by Country in ASEAN Region, 2010

2-11       Country Progress toward Millennium Development Goals 4 and 5, Indonesia

3-1         Components of Basic and Comprehensive Obstetric Care

3-2         Major Killers of Mothers, Fetuses, and Newborns in Low-Income Countries

4-1         Health Facilities at Different Levels of Service Delivery, Indonesia

4-2         Signal Functions for Emergency Obstetric and Newborn Care

4-3         Readiness of Public Hospitals to Provide Comprehensive Emergency Obstetric and Newborn Care (CEmONC)

4-4         Number of Health Providers and Facilities per 100,000 Population and per 1,000 Square Kilometers, Indonesia

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

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

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

6-1         Percent Distribution of Place of Birth by Education of Mothers and Welfare Quintile: Indonesia, 2007

6-2         Percent Distribution of Live Births during Five Years Prior to 2007 Survey by Place of Birth and Province, Indonesia

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)

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)

7-2         Health Insurance Programs: Indonesia, 2013

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

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

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

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

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

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

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

A-8        Percent Distribution of Births in the Five Years Preceding IDHS (Including Current Pregnancies) by Fertility Planning Status, Indonesia: IDHS, 1991-2012

Page xiii Cite
Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
×

A-9        Total Wanted Fertility Rate and Total Fertility Rate in the Three Years Preceding IDHS, Indonesia: IDHS, 1991-2012

A-10       Need for Birth Spacing, Selected Countries in South and Southeast Asia: Most Recent Demographic and Health Survey

Figures

2-1         Direct Estimates of Neonatal, Infant, and Under-5 Mortality Rates, Indonesia: IDHS, 1991-2012

2-2         Percentage Contribution of Neonatal Deaths to Infant and Under-5 Deaths, Indonesia: IDHS, 1991-2012

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

2-4         Comparison of Neonatal Mortality Rate (A), Infant Mortality Rate (B), and Under-5 Mortality Rate (C), Indonesia: IDHS, Selected Years

2-5A      Maternal Mortality Ratio: Country Progress, Southeast Asia

2-5B      Under-5 Mortality Rate: Country Progress, Southeast Asia

3-1         Main Causes of Maternal Mortality

3-2         Main Causes of Fetal Mortality

3-3         Causes of 3.6 Million Neonatal Deaths, 192 Countries, Based on Cause-Specific Mortality Data and Multi-cause Modeled Estimates

3-4         Maternal Mortality Ratios: United States, United Kingdom, and Sweden, 1900-2000

3-5         Maternal Mortality Ratio per 100,000 Live Births over Time and Interventions that Contributed to Decline, United States

3-6         Long-Term Trends for Stillbirth Rates in 11 High-Income Countries, 1750-2000

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

5-1         Birth Attendants at Delivery: Indonesia, 2010

6-1         Number of Civil Servants by Level of Government: Indonesia, 2003-2010

7-1         Per Capita Expenditure on Health: Indonesia, 1995-2010 (constant 2010 U.S. dollars)

7-2         Overview of Government Health Resource Flows, Indonesia

7-3         Percentage of Households with Health Insurance by Type: Indonesia, 2009

7-4         Overview of Private Health Resource Flows, Indonesia

7-5         Mean Expenditure for Different Types of Obstetric Care in Government Hospitals in Banten Province, 2006 (U.S. dollars)

Boxes

4-1         Indonesian Health Care Facilities: Health Posts, Health Centers, and Hospitals

4-2         The Case of Baby Dera

6-1         Decentralization and Argentina

Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
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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
Suggested Citation:"Front Matter." National Research Council. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington, DC: The National Academies Press. doi: 10.17226/18437.
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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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images

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

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The Republic of Indonesia, home to over 240 million people, is the world's fourth most populous nation. Ethnically, culturally, and economically diverse, the Indonesian people are broadly dispersed across an archipelago of more than 13,000 islands. Rapid urbanization has given rise to one megacity (Jakarta) and to 10 other major metropolitan areas. And yet about half of Indonesians make their homes in rural areas of the country. Indonesia, a signatory to the United Nations Millennium Declaration, has committed to achieving the Millennium Development Goals (MDGs). However, recent estimates suggest that Indonesia will not achieve by the target date of 2015 MDG 4 - reduction by two-thirds of the 1990 under - 5 infant mortality rate (number of children under age 5 who die per 1,000 live births) - and MDG 5 - reduction by three-quarters of the 1990 maternal mortality ratio (number of maternal deaths within 28 days of childbirth in a given year per 100,000 live births). Although much has been achieved, complex and indeed difficult challenges will have to be overcome before maternal and infant mortality are brought into the MDG-prescribed range.

Reducing Maternal and Neonatal Mortality in Indonesia is a joint study by the U.S. National Academy of Sciences and the Indonesian Academy of Sciences that evaluates the quality and consistency of the existing data on maternal and neonatal mortality; devises a strategy to achieve the Millennium Development Goals related to maternal mortality, fetal mortality (stillbirths), and neonatal mortality; and identifies the highest priority interventions and proposes steps toward development of an effective implementation plan. According to the UN Human Development Index (HDI), 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. This report is intended to be a contribution toward achieving the Millennium Development Goals.

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