Ind Riset Kesehatan Dasar/Basic Health Research, 2007. ... Health Care for
Primary Health Services (Buku Saku Pelayanan Kesehatan Neonatal Esensial: ...
Maternal and Newborn Health Country Profiles
Indonesia Indonesia is on track to achieve MDG 4, however disparities between rural and urban areas, and within provinces need attention to ensure equitable child health services. The annual rate of reduction in the under-5 mortality rate was 4.5 between 1990 and 2011. A focus on neonatal mortality reduction would accelerate the progress further, as this constitutes almost half of all under-5 mortality. The country has made considerable strides to improve maternal survival. Refining the quality of antenatal care, turning attention to the high prevalence of preterm births and increasing coverage of postnatal care would further reduce preventable maternal and newborn mortality.
TRENDS AND POLICIES
Trends in child mortality 1990
2010
MDG target 2015
Deaths per 1,000 live births
85 56 35
28
31
27 17
Under-5 mortality rate
17
Infant mortality rate
Neonatal mortality rate
Trends in maternal mortality Deaths per 100,000 live births
1990
2010
MDG target 2015
600
220
150
Trends in maternal indicators
Per cent (%)
60
51 24.2 9
Per capita total expenditure on health (US$), 2007–20111
77
Out-of-pocket expenditure (% of private expenditure on health), 2007–20111
75.1
Specific notification of maternal deaths
Yes
Midwife personnel authorized to administer core set of lifesaving interventions
Partial
Costed national implementing plans for maternal, newborn and child health available
No
Number of basic emergency obstetric and newborn care facilities2
1,667
Facilities per 1,000 births3
1
Community treatment of pneumonia with antibiotics
No
Oral rehydration solution and zinc for management of diarrhoea
Yes
DHS 2007
61
9
Availability
Sources: Confirmed with UNICEF Indonesia Country Office, unless specified; 1World Health Organization National Health Account database 2012 (retrieved from www.data.worldbank. org); 2There are 1,667 facilities based on the Indonesian Ministry of Health Facility Survey 2011; 3United Nations Population Fund, The State of the World’s Midwifery 2012.
Maternal mortality ratio
DHS 2003
National health policies and services
51
22
Contraceptive Unmet family Women 20-24 prevalence rate planning need married before (met need) age 18
Adolescent birth rate
Sources for figures: Trends in child mortality: 1990 and 2010 child data from UN Inter-agency Group for Child Mortality Estimation, Levels & Trends in Child Mortality, 2011; Report on Achievement of the Millennium Development Goals Indonesia 2010 (IMR); Indonesia Demographic and Health Survey (DHS) 2007. Trends in maternal mortality: 2015 targets from Countdown to 2015 Indonesia Country Profile (retrieved from www. countdown2015mnch.org/country-profiles) and Report on Achievement of the Millennium Development Goals Indonesia 2010; Indonesia 2007 DHS; Indonesia Ministry of Health, Ind Riset Kesehatan Dasar/Basic Health Research, 2007. Trends in maternal indicators: Indonesia Demographic Health Survey (DHS) 2003 and 2007. Notes: Contraceptive prevalence rate proportion of currently married women aged 15–49 who were using some method of family planning at the time of the survey; unmet family planning need: % of women with an unmet need for family planning (spacing or limiting); adolescent birth rate: annual number of births among women aged 15–19 per 1,000 women in the age group.
Maternal and Newborn Health Country Profiles: Indonesia
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Indicators of quality of care Antenatal care
95.2
100
Intrapartum/delivery
91 81.5
80
Postnatal care
79
Per cent (%)
70 60
53
46 40
40
32
29
20
6.8 0 ANC1+
ANC4+
BP Blood measured* sample*
Urine sample*
SBA
Inst. delivery
C-section BF (excl.) PNC within Birth reg. 2 days
Source: Indonesia DHS 2007. Notes: ANC1+: % of women who received ≥1 ANC visit; ANC4+: at ≥4 ANC visits; *% of ANC visit that included measuring blood pressure (BP) and collecting blood and urine samples; SBA: % of births delivered by a skilled birth attendant (doctor, nurse, midwife); inst. delivery: % of births delivered at a health facility; C-section: % of births delivered by caesarean section; BF (excl.): % of children younger than 6 months who were exclusively breastfed; PNC within 2 days: % of women who received a postnatal check-up within 2 days of delivery (calculated by adding the sum of the % of women who received PNC within less than 4 hours, 4–23 hours and within 2 days of delivery and mentioned in the DHS); birth reg.: % of children younger than 5 years whose birth was registered with the State.
AVAILABILITY OF NATIONAL POLICIES1 FOR HIGH-IMPACT INTERVENTIONS SHOWN TO IMPROVE NEONATAL SURVIVAL THROUGHOUT THE CONTINUUM OF CARE2
Preconception
Antenatal4
Intrapartum
Postnatal
- Folic acid supplementation3
- Tetanus toxoid immunization - Syphilis screening - Pre-eclampsia and eclampsia prevention - Presumptive malaria treatment - Detection and treatment of asymptomatic bacteriuria
- Skilled maternal and neonatal care - Emergency obstetric care - Antibiotics for PROM - Steroids for pre-term labour - C-section - PMTCT - Labour surveillance - Clean delivery practices
- Resuscitation of newborn baby - Breastfeeding - Prevention and management of hypothermia5 - Kangaroo mother care5 - Community-based pneumonia management - Emergency neonatal care
Legend: green: policy in place; red: no policy or clear guideline in place. Sources: 1Polices are addressed/mentioned in the National Strategic Plan of Making Pregnancy Safer Indonesia 2001–2010, except as indicated; 2Darmstadt et al., 2005; 3Mentioned but no guidelines indicated in the Ministry of Health Republic of Indonesia and World Health Organization, The National Nutrition Strategy for Children 0–18 Years, 2005; 4Indonesia Ministry of Health, Integrated Antenatal Care Guideline (Pedoman Pelayanan Antenatal Terpadu; Edisi kedua, Dirjen Bina Gizi and KIA. Jakarta, 2012; 5Indonesia Ministry of Health, Pocketbook for Essential Newborn Health Care for Primary Health Services (Buku Saku Pelayanan Kesehatan Neonatal Esensial: Pedoman Tehnis Pelayanan Kesehatan Dasar. Dirjen Bina Kesehatan Masyarakat), Jakarta, 2010. Notes: PROM: Premature rupture of membranes; emergency obstetric care: management of complications-obstructed labour, haemorrhage, hypertension, infection; C-section: caesarean section (detection and management of breech); PMTCT: prevention of mother-to-child transmission of human immunodeficiency virus (HIV); labour surveillance (including partograph) for early diagnosis of complications); kangaroo mother care (care for low birth weight infants in health facilities); emergency neonatal care: management of serious illness (infections, asphyxia, prematurity, jaundice). Reference: Darmstadt, G.L., Bhutta, Z.A., Cousens, S., Adam, T., Walker, N., De Bernis, L. ‘Evidence-Based, Cost-Effective Interventions: How many newborn babies can we save?’ in The Lancet, 2005; 365 (9463).
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Maternal and Newborn Health Country Profiles: Indonesia
READINESS FOR NATIONAL SCALING UP OF NEWBORN CARE
Agenda setting
Policy formulation
Policy implementation
- National needs assessment for newborn care conducted - Local evidence generated for newborn survival - Existence of a convening mechanism for newborn health issues - Focal person for newborn health in Ministry of Health - Key maternal and newborn indicators included in national surveys (e.g. neonatal mortality rate)
- National newborn policy endorsed - Newborn policy integrated into other health policies or strategies - Essential drug list includes injectable antibiotics for primary level care - Midwives authorized to perform neonatal resuscitation - National targets to track newborn health established - Key maternal and newborn indicators included in national health information systems - Community-based cadres authorized to perform neonatal resuscitation (midwives) - Primary-level cadres authorized to administer injectable antibiotics for newborn infections (midwives) - Community-based cadres authorized to administer injectable antibiotics for newborn infections (midwives)
- Supervision system for maternal, newborn and child health established at primary health centre level - Protocol or standard for district hospital care of sick newborns in place - Integrated management of childhood illness algorithm adapted to include the first week of life - Resource requirement for primary health care available for newborns - Resource requirement for secondary- level health care available for newborns (not all) - System for neonatal death audits exists - System for perinatal death audits exists - Cadre identified for home-based newborn care - In-service newborn care training materials for community-based cadres (village midwife) - In-service newborn care training materials for facility-based cadres (village midwife) - Pre-service newborn care education for community-based cadres (village midwife) - Pre-service newborn care education for facility-based cadres (village midwife)
Agenda setting
Policy formulation
Policy implementation
- Local evidence disseminated for newborn survival
- National behaviour change communication strategy - Community-based cadres authorized to administer injectable antibiotics for newborn infections - Primary-level cadres authorized to administer injectable antibiotics for newborn infections - Community-based cadres authorized to perform neonatal resuscitation (not for voluntary cadres) - Costed implementation plan for maternal, newborn and child health - Reproductive, maternal, newborn and child expenditure per child younger than 5 and per woman aged 19-49 - Community-based cadres authorized to perform neonatal resuscitation (not for voluntary cadres) - Primary-level cadres authorized to administer injectable antibiotics for newborn infections (not for voluntary cadres) - Community-based cadres authorized to administer injectable antibiotic for newborn infections (not for voluntary cadres)
- In-service newborn care training materials for community-based cadres (not for voluntary health cadres) - In-service newborn care training materials for facility-based cadres (not for voluntary health cadres) - Pre-service newborn care education for community-based cadres (not for voluntary health cadres) - Pre-service newborn care education for facility-based cadres (not for voluntary health cadres)
Legend: green: benchmark met; red: benchmark not met. Sources: Moran, A.C. et al., 2012. Availability of benchmarks as per UNICEF Indonesia Country Office. Reference: Moran, A.C., Kerber, K., Pfitzer, A., Morrissey, C.S., Marsh, D.R., Oot, D.A., Sitrin, D., Guenther, T., Gamache, N., Lawn, J.E., Shiffman, J. ‘Benchmarks to Measure Readiness to Integrate and Scale Up Newborn Survival Interventions’, in Health Policy Planning 2012: 27(iii29-iii39). Maternal and Newborn Health Country Profiles: Indonesia
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CONTINUING INEQUITIES: Indicators by residence, wealth quintiles and provinces
Disparities Disparitiesby byresidence residence
Deaths per 1,000 live births Deaths per 1,000 live births
U5MR U5MR
IMR IMR
Disparities Disparitiesby byresidence residence Urine Urine sample sample
NMR NMR
1818
1717
3131 6060
Per cent (%) Per cent (%)
4545
2727
Deaths per 1,000 live births Deaths per 1,000 live births
U5MR U5MR
53.4 53.4
41.4 41.4 87.6 87.6
7373
62.7 62.7
3838
3535
33.2 33.2
49.2 49.2
40.1 40.1
Urban Urban
Country Country total total
Rural Rural
Urban Urban
Country Country total total
Disparities Disparitiesby bywealth wealthquintiles quintiles IMR IMR
Disparities Disparitiesby bywealth wealthquintiles quintiles Urine Urine sample sample
NMR NMR total total
SBA SBA
Birth Birth reg. reg.
83.8 83.8 Per cent (%) Per cent (%)
2727 5656
2626
1717 2727
3232
3535
Wealthiest Wealthiest
Country Country total total
1717 7777
Poorest Poorest
U5MR U5MR
IMR IMR
53.4 53.4 95.4 95.4 22.9 22.9
7373
43.8 43.8
56.6 56.6
22.6 22.6 Poorest Poorest
Most Mostand andleast leastaffected affectedprovinces provinces
40.1 40.1
Wealthiest Wealthiest
Country Country total total
Most Mostand andleast leastaffected affectedprovinces provinces Urine Urine sample sample
NMR NMR
SBA SBA
Birth Birth reg. reg.
97.3 97.3
9696
4646 2222
DIY DIY
1919 WS WS
DIY DIY
1313 WS WS
CKCK
93.8 93.8
69.6 69.6
Per cent (%) Per cent (%)
7474
WS WS
Birth Birth reg. reg.
70.5 70.5
2424
Rural Rural
Deaths per 1,000 live births Deaths per 1,000 live births
SBA SBA
32.8 32.8 18.7 18.7
12.8 12.8 Maluku Maluku
DKIJ DKIJ
Maluku Maluku
DKIJ DKIJ
Maluku Maluku
DIY DIY
Sources: Indonesia DHS 2007. Notes: Comparison of data is by residence (rural versus urban versus country total), wealth quintiles (poorest versus richest versus country total) and by provinces (most affected versus least affected); urine sample (obtained during ANC visit); SBA: % of pregnancies delivered by skilled birth attendant; birth reg.: % of children younger than 5 years whose birth was registered with the State. Provinces: WS: West Sulawesi, DIY: DI Yogyakarta, CK: Central Kalimantan, DKIJ: DKI Jakarta.
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Maternal and Newborn Health Country Profiles: Indonesia
EQUITY FOCUS: Indicators by residence, wealth quintiles and provinces
Residence Indicator
Quintiles
Rural
Urban
Poorest Wealthiest
Most and least affected provinces
U5MR (country avg: 35%)
60
38
77
32
M: West Sulawesi (96); L: DI Yogyakarta (Java; 22)
NMR (country avg: 17%)
24
18
27
17
M: West Sulawesi (46); L: Central Kalimantan (13)
IMR (country avg: 27%)
45
31
56
26
M: West Sulawesi (74); L: DI Yogyakarta (Java; 19)
Informed pregnancy complications at ANC, % (country level: 38.8%)
35.4
43.3
25.7
50.5
M: Maluku (16.1); L: West Java (50.8)
Blood pressure taken (country avg: 90.7%)
88.5
96.4
81.5
98.0
M: Maluku (69.1); L: DKI Jakarta (98.9)
Blood sample taken (country avg: 29.2%)
25.7
33.9
22.6
37.2
M: Maluku (17.6); L: DKI Jakarta (58)
Urine sample taken at ANC, % (country level: 40.1%)
33.2
49.2
22.6
56.6
M: Maluku (12.8); L: DKI Jakarta (69.6)
Skilled birth attendant at delivery (country level: 73%)
62.7
87.6
43.8
95.4
M: Maluku (32.8); L: DKI Jakarta (97.3)
Percentage delivered by C-section (country level 6.8%)
3.9
11
1.8
16.8
M: Central Kalimantan (1.4); L: DKI Jakarta (13.8)
17
14.5
22.7
10.7
M: Papua (66); L: DI Yogyakarta (Java; 2.0)
PNC within 2 days (country avg: 70.3%)
70.6
69.1
66.6
67.8
M: Papua 26.9; L: DI Yogyakarta (Java; 93.5)
Birth registration (country avg: 53.4%)
41.4
70.5
22.9
83.8
M: Maluku 18.7; L: DI Yogyakarta (Java; 93.8)
Exclusive breastfeeding (country %: 32)
-
-
-
-
% who received ORS or RHF (country level %: 46.1)
47.4
43.9
47
38.7
M: North Sumatra (31.8); L: DI Yogyakarta (Java; 78.9)
% continued feeding and given ORT and/or increased fluids (country avg: 54.3%)
55.8
51.7
54.5
48.4
M: Banten (33); L: DI Yogyakarta (Java; 89.7)
% of under-5 children with symptoms of ARI and/or fever whom advice or treatment was sought from a health facility or provider (country avg: 65.9%)
63
70.5
50.6
73.6
M: Maluku 42.6; L: Bali (83.2)
82.8
87.4
71.9
89.2
Antenatal
Intrapartum
Postpartum No postnatal check-up (country total: 16.4)
Children younger than 5 years
DPT3 (country avg: 84.8%)
M: West Papua (56.9); L: Central Java (100)
Sources: All data from DHS 2007 except for U5MR, IMR and NMR totals, which are from UN Inter-agency Group for Child Mortality Estimation, Levels & Trends in Child Mortality, 2011.
Maternal and Newborn Health Country Profiles: Indonesia
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Backstopping midwives with life-saving technology In an innovative arrangement to help midwives improve their service to women and children at the village level, Nokia, PT XL Axiata (telecommunications service) and UNICEF teamed up in 2012 to provide 200 midwives in West Lombok with a phone and application service called Nokia Life Info Bidan, which sends useful SMS information on maternal and child health. West Lombok is located in West Nusa Tenggara, a province with one of the highest maternal and child health death rates in the country. UNICEF and Nokia provide the cellular phones while PT XL Axiata provides 25,000 rupiah worth of airtime every month.
Spotlight on UNICEF work
Nokia Life Info Bidan, which sends useful SMS information on maternal and child health, highlights healthy practices in pregnancy, safe motherhood, nutrition and immunization to early child development and learning; the midwives discuss the messages in mothers’ classes, during appointments in the posyandu (health clinics) or wherever they meet with the community. “I will note the messages down and put them in a book so that I can discuss them with cadres and community members although I can only get a cellular signal from one room in my house,” explained Luluk, who lives in Mareje Timur, a village in the hills some two hours from the district capital. The project’s baseline survey revealed that all midwives used a mobile phone and most (85 per cent) were interested in SMS health information, as were 53 per cent of their patients. An assessment of midwives’ knowledge suggested the SMS messages should focus on areas of lowest scores – postpartum care, pneumonia and malaria. The initial monitoring reports confirmed a high use rate (97 per cent) of messages that reached patients through the midwives.
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Maternal and Newborn Health Country Profiles: Indonesia
Employing village midwives in Indonesia has been a successful strategy to reduce the urban–rural gap in skilled attendance at delivery. The Government’s village midwife programme (bidan di desa programme) provided one-year midwifery training between 1989 and 1996. When a critical mass of midwives was reached in 1996, the training was replaced with a three-year diploma course for high school graduates, which remains in place. Once trained, the midwives are assigned to a village or community. This approach has had a positive impact on linking communities with the formal health sector and on increasing the coverage of care for mothers and newborns. Additionally, the partnership programme in which village midwives work with traditional birth attendants has had a positive impact on coverage of care. Village midwives in Indonesia provide the whole spectrum of maternal and newborn care, from promotional to preventive, to curative care. They conduct deliveries and provide essential pregnancy and newborn care, including management and referral for complications. Midwife-assisted deliveries take place at the patient’s home or the village midwife’s home. Keeping their professional knowledge up to date is necessary to provide quality advice and counselling to clients and it is important for job satisfaction. Although formal training opportunities (workshops, seminars, and meetings) exist, the frequency and coverage are not optimal.
©UNICEF/2012/Hasan
“I will note the messages down and put them in a book so that I can discuss them with cadres and community members although I can only get a cellular signal from one room in my house”
Background