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
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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.
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Copyright 2013 by the National Academy of Sciences. All rights reserved.
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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.
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.
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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
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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
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
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.
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Contents
3 Maternal, Fetal, and Neonatal Mortality
4 The Indonesian Health Care System
7 Strengthening the Financing of Maternal and Neonatal Health
Appendix Fertility Decline in Indonesia and Its Relationship to Maternal Mortality
TABLES, FIGURES, AND BOXES
Tables
2-1 Estimated Maternal Mortality Ratio, Indonesia: IDHS, 1994-2012
2-2 MMEIG versus IHME Estimates of Maternal Mortality Ratio: Indonesia, 1990-2010
2-7 Model-Based Estimates of Under-5 and Infant Mortality Rate, and Annual Reduction Rate, Indonesia
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
Figures
2-1 Direct Estimates of Neonatal, Infant, and Under-5 Mortality Rates, Indonesia: IDHS, 1991-2012
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
3-4 Maternal Mortality Ratios: United States, United Kingdom, and Sweden, 1900-2000
3-6 Long-Term Trends for Stillbirth Rates in 11 High-Income Countries, 1750-2000
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
Boxes
4-1 Indonesian Health Care Facilities: Health Posts, Health Centers, and Hospitals
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| 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 |
| 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 |
