1. Socio-Demographic Profile
IDHS 2002-2003 data shows that there is an equal proportion of women and men in the population. Sex composition of the population does not show significant variation by urban – rural residence. The data further depicts Indonesia as a young population, with a large proportion of the population being the younger age groups.
Youth population constitutes 28.9 % of total population, two third of them are adolescents (10-19 years).
Women are becoming better educated. Percentage of ever-married women with some secondary school increased from 28 percent in 1997 to 38 percent in 2002-2003. However, men tend to be more highly educated than women.
The TFR is 2.6, which is slightly lower than the corresponding rate of 2.8 in 1997. Rural fertility is higher than urban at almost every age. The peak of child bearing among all women is age 25-29. IDHS 2002-2003 indicates that the age pattern is the same as that observed in the IDHS 1997.
Latest MMR is 307 / 100,000 live births, which is still unacceptably high compare to other countries in the region. Although the ratio has decline during the last 10 years, the decrease is considerably slow compare to other related indicators such as Infant or Child Mortality Rates.
Overall median birth interval is 54 months, which is much higher than the previous IDHS. 13 percent of births in Indonesia occur less than 24 months after the previous birth.
Since 1997, there has been a slight decrease in the proportion of adolescents who have begun child bearing. 10 percent of adolescent women have started childbearing compare to 12 percent in 1997. However, it tends to be increased in urban area.
2. Review on policy and strategy in light of ICPD and MDGs
Global commitment on maternal related issues has been acknowledged during the ICPD 1994 in Kairo. Two goals (Goal 3 & 4) are specifically addressing maternal issues, however, the others are inter-related in improving maternal health in general. Those goals are: (1) Universal education, (2) reduction of infant and child mortality, and (3) Reduction of maternal mortality, and (4) Access to reproductive and sexual health services including family planning.
A new set of benchmarks has been agreed upon in a special session of the review of ICPD in 1999 (known as ICPD+5). Two out of four areas are addressing maternal health; (1) Reproductive health care and unmet need for contraception. Governments should strive to ensure that: (a) By 2015 all primary healthcare and FP facilities are providing EOC, safe and effective FP methods; prevention and management of RTIs, including STDs. By 2005, 60 percent of such facilities should be able to offer this range of services, and 80 percent by 2010. (b) Reduce the unmet need by 50 percent by 2005, 75 percent by 2010, and 100 percent by 2050. (2) Maternal mortality reduction. All countries should continue their effort so that globally, by 2005, 80 percent of all births should be assisted by skilled attendants; 85 percent by 2010, and 90 percent by 2015.
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.
|3. Status and Analysis|
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
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.
Skilled birth attendance and Emergency Obstetric Care (EmOC).
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
Ante Natal care
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.
|4. Challenges and Opportunities|
|5. Strategies recommended|
|6. Priority areas for Government|
2. Increase CPR through
3. Community involvement
|7. Priority areas for UNFPA support in 7th Country programme (2006-2010)|
- At policy level:
- At operational level:
- At monitoring and evaluation: