2. Review on policy and strategy in light of ICPD and MDGs

In the year 2000, the 189 United Nations member States met at the Millennium Summit and committed to the 8 goals and 18 targets known as Millennium Development Goals (MDGs). Goal 5; Improve maternal health, covers target 6: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio. In this respect, Indonesia will have to strengthen the strategy in the reduction of maternal mortality from 421/100,000 (IDHS 1991) to nearly 100 / 100,000 live births in 2015.

Indonesia MDGs report (May 2004) has added 2 additional targets under Goal 5. Those are (1) proportion of births assisted by skilled attendants, and (2) Contraceptives Prevalence Rate.

Following up the global commitment, Indonesia responded by (1) reaffirming the ratified ICPD with Law No. 23 / 1992 on Health, (2) Amendment of Law No 10 / 1992 on population and family development, and (3) Conduct a National Workshop on Reproductive Health in 1996 with the main output of the establishment of National Committee on Reproductive Health. The roles of the committee include directing policies and strategies for intervention, monitor task forces activities, and facilitate collaborations with other relevant parties.

The 2nd workshop was conducted 7 years later (September 2003) and has put the ground work for a National Policy and Strategy on Reproductive Health. The workshop has also revisited the structure of the Committee and has brought the coordination up to the coordinating ministry level, which is MENKOKESRA (previously it was under the coordination of Ministry of Health).

Recognizing the need to improve maternal and neonatal health, Government of Indonesia launched the Making Pregnancy Safer initiative with the following goals: protecting reproductive and human rights by reducing the burden of unnecessary illness, disability and death associated with pregnancy, childbirth and neonatal period.

Government of Indonesia is pursuing decentralization, guided by Law No. 22 / 1999 and Law No. 25 / 1999. The decentralization has changed the roles and function of MOH, who is the leading sector for issues of maternal health at all levels (central, provinces and districts), which will (and has) affect programmes and approaches to improve maternal health. 

Maternal death

The issue of high maternal mortality remains in the top of health care agenda in Indonesia. Different studies report a wide range of estimates of MMRatio, from a couple hundred to four times that level, but a range of estimates of 300 – 400 maternal deaths per 100,000 live births has been generally accepted as the prevailing level. This level means that in Indonesia a woman dies every hour from pregnancy, complications during delivery, late referral to hospital services and poor emergency obstetric care . With the current trends, the MDG target is unlikely to be achieved unless extra efforts are made to reduce MMR.

Data from various sources show that there is substantial variation in MMR between provinces. Although it is difficult to estimate MMR at district level (sometime even at provincial level), UNFPA has supported the CBS (Central Bureau of Statistics) to estimate the MMR at 34 districts in South Sumatra, West Java, West Kalimantan, and NTT. The ratio varies from 266 in Sumba Barat (NTT) to 561 in Ciamis (West Java).

Major causes of maternal death are hemorrhage (28%), eclampsia (24%), sepsis (11%), abortion complication (6%), obstructed labour (5%), and others (26%) . Those complications were not treated properly as most of them had not received quality care.

Reproductive morbidity and underlying causes of maternal death
Other dimension of maternal health in Indonesia is RH problems that affect women before, during and after their childbearing year. Those include reproductive tract infections and other pregnancy related morbidity, which receive less attention compare to the main causes of maternal death.

Chronic energy deficiency is another contributing factor to maternal mortality. In 2002, 17.6 percent of women at reproductive age suffered from chronic energy deficiency. Prevalence of anemia is also alarmingly high; 51 percent among pregnant women and 45 percent among post partum. The 1995 HHS indicated that 39.5 percent of women at reproductive age are suffered from anemia (cut off point of Hb level is < 12 gr/dl). Among others, poverty and gender bias are the background of those issues.

Neonatal death

Infant mortality rate (IMR) has declined from 68 per 1,000 live births in 1991 to 35 per 1,000 live births in 2002. IDHS 2002-2003 has also showed that infant mortality has decline in almost all provinces, however, updated figure of neonatal death as indicator closely related to quality of maternal care is not available.

Skilled birth attendance and Emergency Obstetric Care (EmOC).
Six in ten births in Indonesia are still delivered at home. Births in rural areas are almost twice likely to be delivered at home than those in urban areas. The proportion of births attended by health professionals has only increased by approximately 28 percent, from 40.7 in 1992 to 68.4 in 2002; not to mention the huge disparities between provinces. South East Sulawesi had the lowest rate at 35 percent and Jakarta the highest at 96 percent.

Despite the fact that more than 68 percent deliveries were attended by skilled birth attendance, quality of the services are questionable. The recent assessment (May-June 2004) has indicated that among 260 midwives in 4 provinces most of them could not get the require number of ‘delivery cases’ during their training, therefore most of them do not have the competency to assist the delivery. Let alone the insufficient equipment and medications they have.

A huge number of Community Midwifes (BDD – bidan di desa) are recruited and posted in villages across Indonesia. It has been and is a key strategy for addressing reproductive and maternal health issues at the local level. However, the strategy was not comprehensive and somehow inadequate to maintain the availability of such skilled personnel at village level. Those would include adequate support of logistics (equipment, medication, IEC materials, etc), appropriate in-service training, and other human resource development plan. Monitoring and supervision are also lacking resulting to the low compliance to the standard and less motivated providers and at the end would have negative impact to the quality of services.

Almost all district hospital provides emergency obstetric care, which include section caesarean facility. Although, accurate data on section caesarean rate are difficult to get. Some field observations revealed that the services are tends to be underutilized due to some barriers such as geographical barriers and high cost. In addition, as districts hospitals are understaffed, trained health providers could not be available for 24 hours per day, 7 days per week; quality has also been the issues.

CPR and unmet need

IDHS 2002-2003 indicate that 54 percent of ever married and 57 percent of currently married women are using modern contraceptives; injectables are the most commonly used method of both group (26 and 28 percent, respectively), followed by the pill ( 13 percent for both ever-married and currently married). Male participation in the CPR is 0.9 percent of condom use, and 0.4 percent of male sterilization. There is slight decrease of unmet need for FP (9 percent in the IDHS 2002-2003). However, it is assume that the actual unmet need would be higher than the reported data as the survey was only addressing married couples. Thus, unmet need for contraceptives in general population, which include individuals, was not assessed. Unmet need would lead to unwanted and unintended pregnancies. Being unwanted, women would tend to terminate her pregnancy, and as abortion is illegal in Indonesia, pregnant women would seek for unsafe services, which would put her live at risk.

Ante Natal care

Compared with data from the IDHS 1997, data from the current survey shows a slight increase in ANC provided by health providers, from 89 percent in 1997 to 92 percent in 2002. Most of them (almost 80 percent) have complied with the recommended frequency of minimum ANC visits, which is 4 times during pregnancies; and 7 out of 10 pregnant women had their first ANC visit in the first trimester as recommended by the programme.

Adolescents RH - Reproductive rights

Issues of access to RH for individuals including youth and adolescents. Problems of reproductive and maternal health are also contributed from adolescent groups. IDHS data indicated that almost 10% of pregnancies are among women at 15-19 age group. Susenas 1998 has also indicated that about 10% of women of 25-34 age group reported that they have ever married before age 16. Access to reproductive health services is somehow difficult for adolescent; cultural barrier, unfriendly services, and lack of supportive policy make it even more difficult to access.

It could be concluded that factors contributing to reproductive health include: lack of access to quality reproductive health services and emergency obstetric care (EmOC); insufficient access to skilled birth attendance, insufficient access to contraception; unsafe abortion; maternal anemia and malnutrition; malaria and tuberculosis; and social and cultural barriers – such as low awareness of and priority for safe motherhood issues among communities including decision makers. Poverty and gender bias have been in the background of those issues.