This report describes a study undertaken by the Joint Committee on the Reduction of Maternal and Neonatal Mortality in Indonesia of the U.S. National Academy of Sciences and the Indonesian Academy of Sciences. This study was conducted in the context of the UN Millennium Development Goals (MDGs), examining Indonesia’s attempts to fulfill MDGs 4 and 5 dealing with maternal and infant and child mortality.
This chapter presents eight general recommendations designed to guide future efforts to reduce maternal and neonatal mortality in Indonesia. Other chapters of this report contain complementary recommendations more technical in nature that do not depend on adoption of the principal recommendations but that, individually, might improve the treatment and survival probability when mothers and newborns confront medical emergencies.
The joint committee believes that the maternal mortality ratio in Indonesia can be reduced to the best achievable through modern medicine only if all births take place in facilities with rapid access to comprehensive emergency obstetric and neonatal care (CEmONC) capabilities. As defined by the World Health Organization, a CEmONC facility must be staffed by trained doctors, nurses, and midwives and must be able to perform cesarean sections, provide blood transfusions, undertake vacuum delivery of the baby, administer magnesium sulfate and antibiotics, and render the other services necessary to remedy those conditions that most commonly cause maternal or neonatal mortality in Indonesia. The joint committee recognizes that in Indonesia, as in other countries, most births occur without problems. The difficulty (which has political ramifications) is that it is not always possible, even in a well-equipped hospital, to predict with certainty which pregnant woman or newborns will require emergency care. Only if all women give birth in a facility with ready and rapid access to comprehensive emergency obstetric and neonatal care can all cases in need receive the necessary care. This is the solution adopted by nearly all countries that have succeeded in minimizing mortality in childbirth.
Ideally, all women in Indonesia should be able to give birth in facilities capable of basic emergency obstetric and newborn care (BEmONC), which includes intrapartum monitoring, parenteral antibiotics, oxytocic drugs, anticonvulsants, manual removal of the placenta, postabortion care, forceps or vacuum delivery, and neonatal resuscitation. If a blood transfusion or cesarean section is required, timely transfer to a CEmONC facility is a necessity.
Recommendation 1—Facilities. Indonesia should seek to ensure that all births occur in a certified (i.e., independently accredited) facility with either basic or comprehensive emergency obstetric and newborn care (BEmONC or CEmONC) capabilities. As an immediate first step toward realizing universal access to comprehensive emergency obstetric and neonatal care when necessary, clear referral links should be established between certified BEmONC facilities and their CEmONC counterparts throughout Indonesia. Every effort should be made to ensure that every facility designated as a CEmONC facility has the necessary staff, supplies, and equipment and is fully prepared to provide the required emergency obstetric and neonatal care 24 hours a day. To that end, a system of accreditation and monitoring of such facilities must be put in place and repeated periodically.
With a few important exceptions, most complications leading to maternal and fetal deaths during childbirth cannot be predicted. Thus medical interventions for these complications must be readily available for all women and newborns. Because most maternal, fetal, and newborn deaths occur during labor, delivery, and the immediate postpartum period, the interventions for any complications that arise need to be easily accessible during labor and after delivery. Few of these interventions are available in the home, and, unfortunately, in most low-income countries many of these interventions are not provided by clinics. For these reasons, this committee advocates the use of hospitals with CEmONC capabilities in which all the required signal functions are available for all births.
In Indonesia, about one-third of maternal deaths in childbirth are attributable to hypertensive disorders of pregnancy and another 20 percent to postpartum hemorrhage (see Table 2-8 in Chapter 2). In this context, a sound prenatal care program may facilitate identifying those women at risk for these potentially fatal conditions and the arrangements needed for childbirth in a CEmONC-rated hospital prepared to administer the necessary treatments. The interventions needed to reduce maternal, fetal, and neonatal mortality are well known, and there is every expectation that if these interventions were made available to pregnant women and their newborns, pregnancy-related mortality rates in Indonesia would approach those in high-income countries.
The question that arises, then, is not what needs to be done, but how to make these interventions widely available and ensure they are performed in an appropriate and timely manner. Treatment of maternal conditions can have a profound impact on fetal and neonatal deaths, and when they are applied appropriately, most fetal and many neonatal deaths can be eliminated. Quality performance is crucial. But because the required intervention in each case is usually not apparent in advance, a systems approach that provides the resources and personnel required at the moment of need will offer the best chance of success. This approach involves defining the population needing care, the goals of that care, and the necessary facilities, personnel, and cost (taking into account the resources and personnel available in clinics, hospitals, and homes), and then creating a system of care commensurate with the resources. Such an approach is conducive to the most success in reducing maternal, fetal, and neonatal mortality.
Another benefit would be a reduction in the morbidity that affects many mothers who survive complications of childbirth. Often these complications result in long labor, which a CEmONC hospital can halt with a cesarean section. In other settings, it may result in an obstetric fistula or other impairment to the mother.
Such changes do not occur overnight, however. At present, very few hospitals in Indonesia are internationally accredited, and most are not accredited domestically. In 2012 the Ministry of Health mandated that public and private hospitals be accredited by the U.S.-based Joint Commission International (JCI), but few have completed the process. Accreditation is likely to have a salutary effect on quality of care, especially if the associated inspections are repeated periodically. The government should provide incentives for rapid compliance with the requirements of international accreditation for all CEmONC and BEmONC facilities A special effort must be made to direct women identified as high risk to the hospitals able to care for them, and they should have access to insurance to cover the cost.
Some recent efforts merit attention. One is a program to upgrade the status of local health clinics (puskesmas) to BEmONC status. Another is a program of maternal health insurance (Jampersal). Among other things, it provides for universal free delivery services at public clinics and hospitals. These kinds of insurance schemes have been shown internationally to be instrumental in making it easier for women to give birth in health institutions rather than at home. In this regard, the latest (2012) Indonesia Demographic and Health Survey has revealed a marked increase in births occurring in health institutions. Although it may be too early to draw a definitive link between this and the current efforts, these findings could auger well for the future.
In the meantime, community health centers and midwives must continue to serve their patients. The transition will occur as BEmONC and CEmONC facilities, supported by effective health insurance plans, begin to provide adequate services and gain the confidence of patients and their families. At that point, midwives will provide the essential complementary services by assisting in the preparation of birth plans, arranging transport where required, providing normal prenatal, perinatal, and postpartum care, and super-
vising the volunteers at the posyandus. Midwives should have access to limited training or retraining. At the same time, substantial investment must be made in professionally run, well-equipped safe delivery facilities able to provide 24-hour service. Such facilities would not necessarily be hospitals. The BEmONC clinics now found in all districts could be brought up to accreditation level and linked with CEmONC facilities when blood transfusions and cesarean sections are required.
Table 4-5 in Chapter 4 reveals that in parts of Indonesia private hospital services have become much more significant over the last decade and may be able to play an important role in increasing access to good-quality maternity care. These institutions would include both general hospitals and small maternity hospitals (rumah sakit bersalin). Although the joint committee was unable to obtain sufficient data to assess the role of these institutions, under proper regimes of regulation, certification, and financing they could also contribute to accelerating reductions in maternal mortality. They should be considered part of strategies to expand access, where relevant.
Some observers believe Indonesia should look to other middle- and low-income countries for examples of community services and at-home delivery. Indonesia is a large country, and some regions have much in common with the low-income countries, although the majority of maternal deaths occur in the richest and most populous regions. The community-based childbirth system common to low-income countries has not proven successful in achieving continued reductions in the maternal mortality ratio (MMR) or neonatal mortality rate (NMR) throughout Indonesia. Meanwhile, the hospital system is understaffed and underequipped, and insurance plans that would give poor people access to health care are not yet permanently in place. And yet facility-based systems have been a big factor in greatly reducing the MMR in other countries. Either path would require significant resources, time, and commitment. Pursuing both paths at the same time might well create future conflicts, confusion, competition for funds, and ultimately, competition for patients between new and strengthened CEmONC facilities and newly retrained midwives. In any case, it does not appear possible to enable midwives to deal with the most common causes of maternal mortality in the home without the capacity to carry out cesarean sections and blood transfusions. It is unlikely, then, that further progress will be made before more women are able to give birth in accredited facilities.
The following recommendations deal with the major components of the system described in recommendation 1.
Recommendation 2—Strategies and Plans. Technical strategies, implementation plans, and a road map to achieving high coverage with quality maternal and neonatal health (MNH) services should be developed across a range of Indonesia’s diverse environments—all reflecting local conditions and feasible approaches over 5-, 10-, and 20-year time horizons.
Those creating an Indonesian plan to reduce maternal, fetal, and neonatal mortality should seek to reduce the disparities in pregnancy-related services and outcomes between east and west, rich and poor, and rural and urban Indonesia. A one-size-fits-all plan will not sufficiently address the significant regional and socioeconomic differences characterizing Indonesia, and thus several different strategies may be required. In allocating resources, choices will inevitably have to be made. However, they should be made openly, with local participation, and based on balancing the objectives of service equity and total lives saved.
Indonesia’s districts vary widely in population density, personal wealth, and numbers of doctors and other health workers, as well as in unalterable features such as isolation, island geography, and transport difficulties. Within the resources of Indonesia, and probably those of any country, it is inevitable that technology and service-centered indicators such as maternal mortality ratios and neonatal mortality rates will vary. About 50 percent of the population of Indonesia resides in rural areas, which account for 64 percent of childbirth deaths, and about 50 percent live in urban areas, which account for 36 percent of childbirth deaths. Highly populated Java, Bali, and Sumatra, containing both urban and rural areas, account for 68 percent of deaths, whereas predominantly rural Kalimantan, Sulawesi, and Eastern Indonesia account for 22 percent. Seventy-four percent of childbirth deaths in urban areas occur in hospitals, com-
pared with 48 percent of those in rural areas. About 29 percent of deaths occur at home. This does not mean that hospitals in rural areas are better prepared, but probably reflects the fact that more frequently in urban areas many women attempting childbirth at home and encountering difficulties are brought to nearby hospitals too late to be saved. In rural areas, the hospitals are often too far away to attempt transfer without prior arrangement. Alternative strategies must be found for the rural and eastern parts of the country to ensure that recommendation 1 and others are achieved.
The nature of the regional imbalance in Indonesia is not just a matter of distribution of resources and facilities among provinces and districts, but also of geography. The provinces are much larger than the Jakarta area, and although they may have a comparable number of health providers per capita, those providers are sparsely distributed, and reaching the necessary facilities during childbirth may be extremely difficult. Reducing the practical effect of this imbalance would require more than adding health providers to the existing facilities because many of the facilities themselves are inaccessible to many families. This problem is inherent in a country with more than 13,000 islands, and must be addressed with commensurate actions. In rural areas, more people use private facilities—hospitals, clinics, or doctors’ offices— where government control is lighter and fees may be lower. Applying national standards to private hospitals and implementing funding mechanisms that cover childbirth might lower the mortality rate, but the bills are paid and choices are made by local elected officials, and ultimately by families.
The Indonesian health system was designed to be community-based. However, this approach has not resulted in reduced mortality at childbirth. At present, Indonesia has an overabundance of incompletely trained midwives who offer delivery services at home. They now face increased competition for their services and difficulty in accessing employment opportunities within the system (Ministry of Health, 2007; Ministry of Health, Center for Health Resources Development, 2011; Heywood and Harahop, 2009; Shankar et al., 2008). Because most complications cannot be reliably predicted before or during labor, they all too often go unrecognized in the home until it is too late. It follows that the most promising future strategy for reducing the MMR and MNR in Indonesia is to ensure that most if not all deliveries take place in BEmONC or CEmONC facilities.
Although midwives are the most qualified attendant at about 60 percent of births in both rural and urban Indonesia, in the last decade the number of births attended by ob-gyn’s increased from 17 percent to 28 percent in urban areas and from 5 percent to 12 percent in rural areas. Over the same period, the number of births presided over by traditional birth attendants dropped from 20 percent to 7 percent in urban areas and from 42 percent to 20 percent in rural areas (see Table 4-6). This movement indicates an increase in demand for quality childbirth care that must be nurtured and directed toward capable facilities.
Some interventions such as cesarean sections and blood transfusions are possible only in a CEmONC facility. For emergency conditions that must be treated at such a facility, any emergency transportation mode owned by public or private organizations, including the military, should be used to convey the emergency cases to those facilities.
Recommendation 3—System of Care. Organization of the system of care and standardization of the training and licensing of providers should be centralized under one Indonesian government agency that is represented within the central government as well as at the provincial, district or municipality, and community levels. It should address population-based planning and implementation of all the services involved in childbirth.
Unfortunately, community leaders are under little pressure to take action on maternal and child health. Maternal mortality is relatively rare and newborn mortality is frequently not reported. Locally, there are many competing uses for the funds required and little accountability. Only strong leadership from the central government can effect the changes required to reduce mortality at childbirth.
Creation of a systems approach to obstetric and neonatal care would be greatly facilitated if there were greater coordination among organizations charged with training and licensing care providers, operating health care facilities, setting standards for quality of care, approving birth plans, and collecting data for monitoring performance. At present, these responsibilities are divided among the Ministry of Health,
Ministry of Education, Statistics Indonesia, Indonesian Midwives’ Association, and other agencies. The responsibilities of the government agency should include creating monitoring instruments to evaluate local health centers and local public and private hospital services.
Hospital accreditation is conducted by the Hospital Accreditation Commission (Komisi Akreditasi Rumah Sakit, KARS,). KARS accredits both public and private hospitals, but does not regulate the private practices of physicians and midwives. It examines five key hospital activities: (1) management and administration, (2) medical services, (3) emergency services, (4) nursing, and (5) medical records. Hospital accreditation probably should be left in the hands of this independent agency, and it should be associated with international standards. According to Indonesia’s health minister, as of 2012 only five of Indonesia’s 1,800 hospitals were accredited internationally, and all five were privately owned. As of the same year, 65 percent of the 1,800 hospitals were nationally accredited, and one-third of those were privately owned (Jakarta Globe, 2012).
The training of midwives is carried out by the Ministry of Education, whereas most medical services, including those certifying and employing midwives, are governed by the Ministry of Health. This arrangement limits opportunities for integrated in-service training to complement coursework, especially where an increasing number of midwives are competing for training opportunities with a relatively static number of births. Similarly, a registry of births and deaths (see recommendation 6) could be integrated into service, evaluation, and planning programs if it were carried out by the unique responsible agency.
Finally, it may be useful to consider further work on the minimum service standards (MSS), particularly looking at ways to develop measures and measurement systems that reflect the accountability of service providers to the public and that are relevant, understood, and meaningful to local people (see Chapter 6). To this end, the central government should recognize the limitations of the existing data and data collection when demanding accountability from lower-level governments,, It could provide assistance in developing the instruments by which local communities can demand accountability of local health services providers, such as local health centers at the subdistrict level and regional hospitals at the district and provincial levels. Further work on the MSS could allow for greater “standardization” of the quality of public health services that can be expected by local communities.
Recommendation 4—Training. The system for training skilled birth attendants should be revised to include the training of physicians and nurses who specialize in emergency obstetric, neonatal, and anesthesia services. Training of midwives should emphasize recognition of obstetric emergencies and the design and implementation of birth plans that include prenatal care and evaluation and early referral for complications, as well as, most important, a clear plan for the birth to take place in a BEmONC or CEmONC facility.
The World Health Organization (WHO) and other groups recommend the use of skilled birth attendants for delivery. However, the training and skills of those labeled “skilled attendants” in Indonesia vary widely, and many cannot perform a cesarean section, give blood transfusions, or administer antibiotics— interventions that are often necessary to save a life. Even the ability of the most skilled attendant to save a life is limited if no blood or antibiotics are available, or if the facilities needed for a cesarean section are not accessible.
Standards for the certification and qualification of midwives should be set by the Ministry of Health and reinforced by rigorous examination, accreditation, and re-accreditation. Those creating an effective system of care should pay great attention to the skill level of the birth attendant and the circumstances in which that attendant will attempt to provide life-saving care to the mother, fetus, or newborn. Within any system of care, the capability of the birth attendant is considered crucial. In low-income countries, historically most often the birth attendant has been an unskilled or traditional birth attendant (TBA). For the most part, studies have shown that even with additional TBA training, maternal mortality rates do not decline. Although training in resuscitation may result in some reduction in stillbirths and neonatal mortality, a clear gap remains that warrants a much higher-level skilled birth attendant.
There are 200,000 midwives in Indonesia. It would be a major undertaking to retrain this workforce. Funding for such an undertaking is obviously not available at present. The joint committee believes that at this stage the best investments would be in birthing facilities, along with the associated infrastructure such as transport and health insurance. It is the committee’s opinion that more lives would be saved by facilities that can do cesarean sections, give blood, etc. Training midwives for home delivery or non-BEmONC or CEmONC facilities without these types of skills or resources is unlikely to save many lives in the short or long term.
Midwives will likely have a larger impact on maternal and neonatal survival by focusing on implementation of a certified safe birth plan for each woman and providing other routine services such as family planning, immunizations, and integrated management for childhood illnesses such as diarrhea and pneumonia rather than by managing or treating obstetric emergencies, which generally require a higher skill level. However, training might include some critical childbirth interventions such as administration of misoprostol, treatment of neonatal sepsis or asphyxia, or kangaroo mother care,1 especially in the more remote regions where other services might be unavailable. Still, this approach should not preempt or replace precise planning for safe delivery at an accredited facility. A major review and restructuring of the approach to training for maternal and neonatal care would be necessary to ensure adequate skills in the right numbers, time, and place.
Trained midwives should be formally brought into the health care system; for now, they remain a major provider for births, although many of them lack training in basic emergency care. (As an interim step, all midwives should be given training in neonatal resuscitation, and simple resuscitation equipment should be standard equipment of the midwifery kit.) The goal would be to have them serve as links to referrals to the facility level and therefore gatekeepers for the community and as central players to raise the population’s consciousness that maternal mortality can be prevented with sound antenatal care. In those roles, they can emphasize the importance of antenatal care as central to a healthy delivery and play a bigger part in detecting complications during pregnancy and arranging the required treatment in advance. This process will foster professionalization of care at the community level through a practical approach that leverages the existing village-based midwives whose responsibilities in the area of deliveries will shrink.
Recommendation 5—Financing. Sufficient and effective financing mechanisms for obstetric and newborn services should be established under the supervision of the government of Indonesia to ensure universal access to quality MNH care and strengthen the organization of that care. These mechanisms should include sufficient overall funding for needed services; the appropriate incentives for providers and for women to deliver at a certified facility capable of providing optimal care and to reduce unnecessary or inappropriate care; and effective monitoring and accountability mechanisms to plan and track financing, including some mechanisms for people’s participation.
The government of Indonesia has made significant efforts in recent years to increase its spending on health and to focus that spending more on the poor and on priority health needs. Those needs include reducing maternal and newborn mortality and improving maternal and child health (MCH). These efforts are evident from growing government health spending relative to private spending and also in a number of new insurance programs intended to increase access to maternal and neonatal health services. However, weaknesses in current financing and governance approaches are reducing the effectiveness of these efforts. Also, the gaps in the evidence available indicate that without significant efforts to reform reporting and accountability, it will remain difficult to identify and remedy the bottlenecks hindering the translation of higher spending into better birth outcomes.
Although it is not possible with the data available today to calculate the total spending on maternal and neonatal care, it appears that the amount is insufficient to redress the slow progress in attaining
1 According to WHO, kangaroo mother care is a method of caring for preterm infants in which the infants are carried, usually by the mother, with skin-to-skin contact.
MDGs 4 and 5, and may be below the government of Indonesia’s own targets for spending. Greater resource mobilization and better allocation of existing resources to effective and equitable interventions are needed. Another issue is the complex system of fragmented government funding streams that makes it difficult to determine how much is being spent for what purpose and to coordinate financing for essential inputs such as staff, physical facilities, drugs, supplies, and equipment.
Even taking into account both government and private sources of funding and the recent increases, Indonesia is still spending relatively little overall on health compared with other countries. However, a comparison with some of Indonesia’s better-performing neighbors such as Sri Lanka and Malaysia suggests that the lagging childbirth outcomes in Indonesia do not stem entirely from insufficient current spending but also from underinvestment and insufficient allocation of resources to address priorities.
A maternal and neonatal health financing strategy should explicitly consider the differentials in financing support that may be needed in different physical environments in Indonesia. The total costs of delivering access to good-quality MNH services is likely to be very different in more remote areas (in Eastern Indonesia, for example) than in the densely populated areas of Java and Bali with their better transport infrastructures.
Presently, substantial funds are being transferred to the districts, but with little accountability on how those funds are actually being used. District administrations have economic incentives to use funds in ways that enable them to gather more revenue, and they have political incentives to invest more in health activities that have popular appeal. Both kinds of incentives may conflict with goals aimed at the poor and less powerful groups, such as reducing maternal and neonatal mortality. Similarly, funding mechanisms such as health insurance that encourage better purchasing practices and accountability lose this feature when transferred as block grants to districts. Although some health insurance funds are earmarked to pay for MNH services, at present it is not known to what extent they do so. Thus it is impossible to gauge the benefits of continued or additional support for such mechanisms. Funding differentials for districts are also likely to reinforce health care inequities, including those for maternal and neonatal health, the outcomes of which are much worse in Indonesia’s more remote regions.
Currently, district expenditures on maternal and child health (children under 5) average 12 percent of the Bappenas-targeted expenditure; the fraction spent on maternal and neonatal health is not reported. Some increases in dedicated central government spending on maternal and neonatal health are reportedly nullified by reductions in districts’ own allocations to MNH or local redirection of funds. Furthermore, many districts do not spend their entire allocated health budgets because of inefficiencies in the budget delivery process.
New programs that provide health insurance coverage for childbirth-related services are possibly increasing overall funding. These programs should make full use of the potential of both demand-side and supply-side payment methods to align with efforts to improve service access and quality, especially for poor women. The inclusion of nongovernment providers of clinical and ancillary services, certified for quality, could help support overall access and coverage objectives.
The Ministry of Health has developed costs and fees related to maternal health services nationwide for different classes of hospitals. However, there is a discrepancy between the cost of childbirth services at Class C hospitals used by the poor and the amount the government will reimburse the hospital, ranging from $27 for a normal delivery to $291 for a cesarean section, and this difference may be charged to the patient.
Recommendation 6—Data. Making the appropriate decisions about programs likely to reduce maternal, fetal, and neonatal mortality rates in Indonesia and allocating resources appropriately will require collecting high-quality data on those rates and the causes of morality. These data must be collected locally and nationwide in a routine and standardized manner and used routinely and frequently at the local level for improving the quality of programs and nationally for planning programs and allocating resources.
In many low-income countries, one of the major obstacles to program development aimed at improving pregnancy-related outcomes is the lack of timely and reliable data on these outcomes and their direct and indirect causes and on the impacts of interventions that attempt to improve these outcomes. Without the availability of these data on a national basis and in a timely and frequent manner, the ability of a hospital, geographic area, or political district to compare its outcomes with those of similar entities is limited and the supposed improvements are more difficult to verify. Without data that compare these entities’ current outcomes with those achieved historically, the impacts of newly introduced programs or interventions cannot be evaluated, and sustained improvement will prove elusive. The data should reflect the accountability of service providers to the public and be relevant, understood, and meaningful to the local people.
Presently, Indonesia relies on survey-based data to obtain official measures of maternal-, neonatal-, and child health–related deaths, but these data employ relatively small sample sizes and model-based adjustments, and they yield a wide range of estimates. They are also collected too infrequently to inform programs. Different approaches to measuring mortality rates yield different results and different assessments of the progress made. Estimates employing both the sibling technique and models based on the maternal mortality ratio and childhood mortality rates offer no conclusive assessment of trends and MDG achievements.
Since 2006, the National Institute of Health Research and Development (NIHRD) in the Ministry of Health has collaborated with the Ministry of Home Affairs and local governments (civil registry offices) in the Indonesia Mortality Registration System Strengthening Project (IMRSSP). This project has established a mortality registration system to ascertain the causes (based on the International Classification of Diseases, ICD-10) of all deaths at all ages. The project is supported by WHO Indonesia, the School of Population Health at the University of Queensland, and the Australian Agency for International Development (AusAID). This project should be strengthened through project follow-up and innovative activities involving local governments in line with the era of decentralization. Strengthening might include following steps:
• Follow up the January 2010 joint decree by the ministers of home affairs and of health on reporting of deaths and multiple causes of death to facilitate the recording of events and cooperation between the two sectors at the grassroots level.
• Ensure that efforts by the Ministry of Health to improve the health information system on births, deaths, and multiple causes of death are in line with the Ministry of Home Affairs program aimed at strengthening civil registration and vital statistics based on the existing law on population administration (No. 23/2006).
• Enforce the compulsory registration of vital events, based on the population administration law.
• Encourage close collaboration between local government officials and the Directorate General of Population Administration (AdMinDuk).
• Designate the city or district health officer as the responsible official and the subdistrict health center (puskesmas) as the responsible health institution.
• Continue to apply the IMRSSP methods and procedures as well as training modules and data collection framework in the Sample Registration System (SRS) area.
• Establish networking of NIHRD with local universities, schools of medicine, and schools of public health.
• In addition to strengthening civil registration and vital statistics (CRVS), strengthen the survey-based data sources already established for maternal and neonatal health, such as the Indonesia Demographic and Health Survey (IDHS), Basic Health Survey (Riskesdas), and National Socio Economic Survey (NSES or Susenas), as well as the program-based data management systems such as the Maternal Perinatal Audit Program and PWSKIA (Pemantauan Wilayah Setempat Kesehatan Ibu dan Anak, the local area monitoring system for maternal and child health). The benefits of using data from multiple data sources would be enhanced by improving the capacity of decision makers at the central and regional levels to understand the data produced. In the end,
it will require a broader commitment and cooperation in building the system among a range of key stakeholders, including the Ministry of Health, Ministry of Home Affairs, Ministry of Finance, Ministry of State Apparatus Utilization and Bureaucratic Reform, and Statistics Indonesia (Badan Pusat Statistik, BPS).
Recommendation 7—Community Involvement. Health care at the community level has many strengths, including the women's volunteer committees, posyandus (integrated health posts), and the district health departments. These organizations could make a greater contribution to lowering maternal and infant mortality by supporting the creation and execution of certified birth plans. Such plans would include facilitating transportation and utilizing antenatal care services, immunization, and contraception optimization for all women and children and, most important, planning delivery in a certified BEmONC or CEmONC facility. These volunteer committees should be integrated into an overall system for the provision of services for women and newborns.
Community involvement, including family, community, and midwife, has a long history in maternal health in Indonesia. The posyandu, a community-based volunteer organization, operates once a month to register births, weigh and measure babies, provide nutrition and health information, and immunize infants. Volunteers encourage women with high-risk pregnancies to seek prenatal care in due time and help the women to arrange transportation to a health facility. As part of a multi-tiered system, the posyandu serves as the first line of care, followed by basic professional care at health centers and clinics, and then higher referrals to district and advanced hospitals.
Consistent with recommendation 4 on the role and training of midwives, the current village-based midwives would also focus on community-based activities in support of safe childbirth, including provision of antenatal care and more active development of a birth plan ensuring delivery in a certified facility. The village-based midwife would therefore give her full attention to providing higher coverage and quality of community-based care in cooperation with the work of the posyandu and less to attending deliveries.
Maternal health insurance, particularly for lower-income households, that provides for free or very low-cost birthing services at health facilities (particularly those with BEmONC or CEmONC capacity) should be encouraged and strengthened to support these community-based initiatives.
Recommendation 8—Education and Empowerment. Programs that encourage the education and empowerment of girls and young women in general and are related to childbirth issues in particular should be strengthened. This high-priority action must include clearly measurable and frequently assessed indicators of progress toward these goals, with additional resources provided whenever needed.
Many anthropological studies of Indonesia have revealed a deep-rooted belief system in which maternal and child deaths are influenced by magic, fate, and God’s will. Inquiries into the causes of maternal deaths have uncovered community-held beliefs that little can be done to save the life of a pregnant woman or newborn. Some pregnant women continue to rely on the use of traditional birth attendants instead of skilled experts because these women believe that following traditional beliefs and traditional family practices will lead to a healthy pregnancy and birth.
Over 60 percent of the Indonesian women who die in childbirth have had a primary school education or less. The desires, knowledge, and decision-making power of the mother are critical factors in family decisions on safe childbirth. Educating girls and young women saves lives by enabling a mother to make better decisions, by empowering her in her dealings with other family decision makers, and by giving her the knowledge she needs to effectively nourish and care for her infant.
In Indonesia, a vigorous national family planning program coupled with social change (particularly in the promotion of basic education and increased formal sector employment opportunities for girls) saw fertility, as measured by the total fertility rate (TFR), decline by more than 50 from the late 1960s to the early 2000s, with the TFR reaching a level of 2.6 by around 2002 based on the results of the Indonesia
Demographic and Health Survey (IDHS)—See Table A-2 in the appendix) This development included major declines in fertility among women whose age placed them at higher risk, such as those in their teens and those over 40. Concurrently, there were marked increases in the average intervals between births, and a decline in the percentage of births with intervals under 24 or even under 36 months.
However, with little recorded change in fertility rates since 2000 and a consistent gap in unmet need for contraception as measured by subsequent IDHS reports in 2007 and 2012, there is room for further decrements in fertility that would likely have a positive impact on maternal health. These decrements need to be encouraged by means of a reinvigorated family planning program that should constitute an integral part of safe childbirth services offered to Indonesian women.
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Jakarta Globe. 2012. Only 5 Indonesian hospitals internationally accredited: Minister. February 15. Available at http://www.thejakartaglobe.com/archive/only-5-indonesian-hospitals-internationally-accredited-minister/498295/.
Ministry of Health. 2007. MoH Decree No. 369/Menkes/III/2007—Midwife Standard Definition. Jakarta.
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