Book: Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future

 Reference:

Joint Committee on Reducing Maternal and Neonatal Mortality in Indonesia. 2013. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Retrieved in   https://www.ncbi.nlm.nih.gov/books/NBK201706/pdf/Bookshelf_NBK201706.pdf

Important quotations:

Cost and distance are among the most obvious factors affecting the use of trained attendance and institutional deliveries (Titaley et al., 2010). Particularly in more isolated regions and among poorer and less educated women, even carrying out an effective referral for difficult deliveries is far from easy. As shown in Table 4-6, the change in the most qualified attendant in rural areas is largely reflected in shifts from TBAs to trained midwives—still largely in a community setting. In urban areas, the shift is more from midwives toward doctors and ob-gyn’s, which is one indication, among others, of the much easier access to health personnel and particularly to more professional care when it is needed. [page49]

he preference of women who have a normal pregnancy to give birth in more familiar surroundings, According to this view, trained attendants and institutional deliveries are in effect aimed primarily at women experiencing obstetric complications. This finding is in some ways of greater concern because it suggests that purely supply-side measures may not be sufficient in and of themselves to bring all deliveries into fully safe and secure surroundings. It is also of interest that, although public efforts appear to have been largely successful in convincing women of the importance of regular antenatal check-ups more or less irrespective of how they feel, the same cannot be said of institutional deliveries, even where they involve institutions such as health clinics where the quality of service may still be relatively low. Thus, although the emphasis on supply-side interventions designed to address concerns related to access and cost remain critical, there also appears to be a need for a greater focus on the demand side, particularly at the community level. It should include efforts to educate families about the importance of giving birth under safe conditions and to inform them that a normal pregnancy without obstetric issues is no guarantee that a medical emergency during childbirth affecting the health of either the mother or the newborn child will not arise. [page 50] 

Maternal and newborn care practices in Indonesia are strongly influenced by diverse local belief systems. Central among these beliefs is the role of fate or God’s will in the outcomes of pregnancy and delivery. Indeed, multiple anthropological studies in Indonesia have revealed deep-rooted belief systems in which maternal and child deaths are influenced by magic, fate, and God’s will. Several inquiries into maternal deaths have uncovered community-held beliefs that little can be done to save the life of a pregnant woman or newborn (UNFPA, 2008; Agus, Horiuchi, and Porter, 2012). In some cases, the use of traditional birth attendants (TBAs) is still dominant because women believe that following traditional beliefs and relatives’ suggestions will lead to a healthy pregnancy and birth (Agus, Horiuchi, and Porter, 2012). 

Nevertheless, there has been growing recognition of the benefits of skilled medical care, and yet persistent barriers affect perceptions of quality, cost, and access. Family members of deceased women or children cite problems with health care access, fees, and inattentive medical personnel as factors contributing to deaths. These views suggest that there is recognition that some deaths are indeed preventable and are consistent with pregnant women seeking improved care and resources when barriers are removed. Despite progress in reducing maternal deaths in Indonesia, pregnancy still puts the health of women at risk. This chapter describes Indonesia’s health system, whose primary purpose is to promote, restore, and maintain health, including maternal and neonatal health. The system includes all public and private health services, professional medical attention, traditional healers and birth attendants, and all public health activities (WHO, 2000). 

Any description of Indonesia’s health care system must be prefaced by a physical description of the country itself. Consisting of more than 13,000 islands spread over 1.9 million square kilometers and home to some 240 million people, Indonesia is the second most populous country in Asia and the fourth largest in the world. Its population is characterized by its wide diversity: demographic, economic, social, political, and cultural. About 56 percent of the population lives in rural areas. The country is divided into 34 provinces, each of which has a legislative council headed by a governor. The provinces comprise some 500 districts, divided into nearly 7,000 subdistricts in which there are almost 80,000 villages (Badan Pusat Statistik, 2012)

[page 39]

1.  The Indonesian National Health Development Program is based on a primary health care concept: the community health center is the basic health care facility, supported by hospitals and other communitybased health care facilities. The Ministry of Health (MoH) has overall responsibility for the nation’s health care policy. It manages and operates health care programs, including staffing, education and training, and health services.

2. Community-based health care has been a cornerstone of the public health system in Indonesia since its inception. Early initiatives in maternal and newborn care focused on the provision of care through community health care centers (puskesmas) and village health posts (pustu), all aimed at supplanting the widespread use of traditional birth attendants (dukun) who, though unskilled, were part of the cultural fabric of pregnancy and childbirth throughout the country. However, it was quickly evident that more direct access was needed between trained health providers and the community for better maternal and newborn care. This led to the creation in 1989 of the village midwife program (Bidan di Desa) in which a trained midwife was placed in each village along with a village birth facility (polindes). The village midwife program also became an integrated part of the monthly community health extension post (posyandu) held in each village, thereby offering antenatal care and reproductive health consultations at the village level.

3. These steps were accompanied by the engagement of community health volunteers (kaders)—a measure intended to facilitate outreach to the community and mobilization to promote the utilization of health care services. Since the establishment of integrated health services, several initiatives have been adopted in attempts to enhance this core system of community health care centers, village health posts, village midwives and birth facilities, community health extension posts, and community health volunteers. In addition, efforts have been made to overcome the traditional and sometimes deleterious practices fostered by local tradition and the use of the traditional birth attendants

Indonesian Health Care Facilities: Health Posts, Health Centers, and Hospitals Integrated Health Posts (Posyandus)

 At the village level, the integrated health post 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. The concept of such a center was part of the fourth five-year development plan issued in the early 1980s. About 270,000 posyandus are in place across Indonesia (Ministry of Health, 2010a). Among other things, they register births, weigh babies, maintain growth charts, and provide nutrition education and immunizations. Open once a month and serviced by a skilled health worker, these centers, it is hoped, are helping the women and children of Indonesia overcome major health problems. Indeed, the posyandu was a critical component of the Health for All 2000 initiative because it brought an integrated program of maternal and child health, family planning, nutrition, immunization, and diarrheal control to the village level. 

Health Centers (Puskesmas) Since the 1970s, basic health services, especially primary care, have been centered on the puskesmas, or community health centers. Most health centers are equipped with four-wheel-drive vehicles or motorboats so that they can serve as mobile health centers and provide transportation to underserved populations in urban and remote rural areas. Several midwives are typically stationed at the puskesmas, and obstetrical exam and birthing rooms equipped with the basic equipment are available. Antenatal care at the puskesmas typically includes pregnancy testing, counseling, monitoring of weight gain and fetal development via palpation and a Pinard stethoscope, assessments of maternal hemoglobin levels, blood pressure monitoring, and biochemical tests for proteinuria, although the latter is not consistently available. Birthing facilities include a clean delivery room and basic equipment and supplies such as oxytocin, but they do not fulfill the requirements for basic emergency obstetric and newborn care (BEmONC). 

Patients with complications are referred to either the district hospital or another facility, possibly a more fully equipped puskesmas for BEmONC or comprehensive emergency obstetric and newborn care (CEmONC). Regulations in Indonesia require a minimum of four BEmONC health centers (designated puskesmas) in each district. Based on the 2011 Health Facility Survey (Rifaskes), only 61 percent of districts in Indonesia have at least four BEmONC facilities, and the majority of these facilities are on Java or Bali (Ministry of Health, 2011b). Only 42 percent of the districts located in the eastern part of Indonesia (excluding Sulawesi) have at least four BEmONC-designated health centers. The figures for other regions are Kalimantan, 54 percent; Sumatra, 55 percent; Sulawesi, 66 percent; and Java-Bali, 75 percent (Ministry of Health and UNFPA, 2012). The 2011 Health Facility Survey also reported that 28 percent of BEmONC-designated facilities do not operate 24 hours a day, and those facilities are located mostly in eastern Indonesia (Ministry of Health, 2011b; WHO, 2012).

 In Indonesia, only 45 percent of BEmONC facilities meet the personnel requirement, and only 12 percent have the required equipment. Finally, only 3 percent of BEmONC facilities have all the medications required (Ministry of Health and UNFPA, 2012). Eastern Indonesia (excluding Sulawesi) falls at the lower end. Hospitals Hospitals are the main providers of curative care. Indonesia has four types of hospitals, ranging from teaching hospitals in the country’s major cities to district-level hospitals, where all basic services are provided and the more complicated cases are referred to the higher-level hospitals. Hospitals are open 24 hours a day. However, admission of all patients to a facility is not guaranteed, especially if the patient lacks the ability to pay. In an article published in The Lancet, the director of Indonesia’s oldest maternity hospital, Budi Kemulyaan, admitted that, even in Jakarta, there are not enough hospital beds and not enough financial support for women facing catastrophic health costs (Webster, 2012).