Email: [email protected]
Nutrition, Health Status, Programs and Policy for
Pregnant and Lactating Women in Indonesia
TrihonoSenior Health Advisor
Jakarta, 12 August 2014
Email: [email protected]
Outline of Presentation
1. Maternal Mortality Ratio (MMR)2. Coverage of maternal health services3. Quality of maternal health services4. Health & nutrition status of pregnant
women5. Policy & programs6. Conclusion
Focus on pregnant women
Email: [email protected]
Maternal Mortality Ratioin Indonesia
Source: Prof. Terence H Hull
Email: [email protected]
MMR 1994 - 2012
390
334307
228
359
0
100
200
300
400
500
1989-1994 1993-1997 1998-2002 2003-2007 2008-2012
MM
R/1
00.0
00 L
H
Reference Period
Source: IDHS 1994 - 2012
Email: [email protected]: IDHS 1994 - 2012
Email: [email protected]
Follow up study on maternal death (Population Census 2010)
• Pregnancy related death data was collected during Population Census 2010
• More than 8,000 cases identified, 50% (>4,000 cases) were revisited for verbal autopsy in 2011
• Analysis for identifying cause of death was done, the results i.e.:
Cause of Maternal Mortality (Population Census 2010)Kode ICD 10,
WHO
Underlying cause of
maternal death
RegionIndonesia
Sumatera Jawa-Bali Kalimantan Sulawesi IBT
O00-O08 Pregnancy with abortive
outcome
3.7 4.2 2.7 5.6 4.2 4.1
O10-O16 Oedema, proteinuria, and
hypertensive disorder (HDK)
33.3 33.1 34.9 32.6 25.8 32.4
O44-O46 Placenta previa, premature
separation of placenta and
Antepartum haemorrhage
4.4 2.7 4.3 2.3 3.6 3.3
O30-O43, O47-
O48
Other maternal care related
to fetus and amniotic cavity
and possible delivery
problems
3.0 1.7 0.0 0.8 0.1 1.6
O64-O66 Obstructed Labour 0.5 1.1 0.0 0.6 1.0 0.8
O72 Postpartum haemorrhage
(PPP)
16.4 16.8 28.1 26.3 29.8 20.3
O20-O29, O60-
O63, O67-O71,
O73-O75, O81-
O84
Other complications of
pregnancy and delivery
11.1 6.0 2.9 7.9 5.9 7.2
O85-O99 Complication predominantly
related puerperium and other
conditions
27.6 34.3 27.1 23.9 29.7 30.2
Total100.0
(N=1737)
100.0
(N=3334)
100.0
(N=587)
100.0
(N=979)
100.0
(N=887)
1000
(N=7524)
32.4
20.3
Email: [email protected]
Period of Maternal Death
Period N (%)
Pregnant < 20 weeks 543 7.2
Pregnant > 20 weeks 1,372 18.2
Labor 974 12.9
Post partum 4,634 61.6
Total 7,523 100.0
Source: Follow up study of maternal mortality of PC 2010
Email: [email protected]
Place of Maternal Death
42%
29%
16%
13%
Government Hospital
Home
Private Hospital
Others
Source: Follow up study of maternal mortality of PC 2010
Email: [email protected]
Coverage ofMaternal Health Services
Email: [email protected]
Coverage of ANC, 1991 - 2012
0.0
20.0
40.0
60.0
80.0
100.0
1991 1994 1997 2002 2007 2012
55.163.1
70.481.0 81.5
87.8
Ku
nju
ng
an
AN
C (
%)
Reference period
4+
2-3
1
0
Source: IDHS 1991 - 2012
Email: [email protected]
Coverage of ANC-4 by Provinces, 2010 - 2013
61.4
70.0
0.0
20.0
40.0
60.0
80.0
100.0
Ma
luku
Pa
pua
Pa
bar
Ma
lut
Su
lbar
Su
lte
ng
Ka
lte
ng
Su
ltra
Go
ron
talo
NT
T
Su
lse
l
Ka
lbar
Su
mse
l
Su
mu
t
Ja
mb
i
Sulu
t
Ka
lse
l
Ace
h
Be
ngku
lu
Sum
bar
Ria
u
Ka
ltim
Ba
nte
n
IND
ON
ES
IA
Ba
bel
NT
B
Ja
ba
r
Ja
tim
La
mp
un
g
Ke
p.R
iau
DK
I
Ja
teng
Bali
DIY
2010 2013
Source: Riskesdas 2010 - 2013
Email: [email protected]
Coverage of SBA: 2010 - 2013
79.0
86.9
0.0
20.0
40.0
60.0
80.0
100.0
Pa
pua
Ma
luku
Ma
lut
Su
lbar
NT
T
Pa
bar
Ka
lte
ng
Su
lte
ng
Ka
lbar
Su
ltra
Su
lse
l
Sulu
t
Ja
ba
r
Ba
nte
n
Ka
lse
l
Ria
u
IND
ON
ES
IA
Ja
mb
i
Su
mse
l
Lam
pung
Ka
ltim
Ba
bel
Ace
h
Goro
nta
lo
NT
B
Su
mb
ar
Su
mu
t
Jatim
Be
ngku
lu
Ke
p.R
iau
Ja
teng
DK
I
Bali
DIY
2010 2013
Source: Riskesdas 2010 - 2013
Email: [email protected]
Coverage of PNC: 2010 - 2013
46.8
81.7
0.0
20.0
40.0
60.0
80.0
100.0
Ma
luku
Pa
pua
Pa
bar
NT
T
Ma
lut
Su
lbar
Ka
lbar
Ka
lte
ng
Su
lte
ng
Ja
ba
r
Ke
p.R
iau
La
mp
un
g
Sum
sel
Su
ltra
Ba
nte
n
Sulu
t
Su
lse
l
IND
ON
ES
IA
Ba
bel
Su
mb
ar
Ka
lse
l
Ria
u
Ka
ltim
Su
mu
t
Ace
h
Ja
mb
i
Ja
tim
NT
B
Go
ron
talo
Ja
teng
DK
I
Bali
Be
ngku
lu
DIY
2010 2013
Source: Riskesdas 2010 - 2013
Email: [email protected]
Paradoxical condition
• Coverage of maternal health services is increasing, but Maternal Mortality Ratio is not decreasing.
• Caused by:1. Poor quality of maternal health services2. Health & nutrition status of pregnant
women3. Other social determinants
Email: [email protected]
Quality of Maternal Health Services
Email: [email protected]
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
BA
LI
DI Y
OG
YAK
AR
TA
JAM
BI
DK
I JA
KA
RTA
NU
SA T
ENG
GA
RA
TIM
UR
JAW
ATE
NG
AH
JAW
ATI
MU
R
BA
NTE
N
NU
SA T
ENG
GA
RA
BA
RA
T
JAW
AB
AR
AT
RIA
U
SUM
ATE
RA
SEL
ATA
N
SUM
ATE
RA
BA
RA
T
KA
LIM
AN
TAN
BA
RA
T
LAM
PU
NG
KA
LIM
AN
TAN
TIM
UR
GO
RO
NTA
LO
SULA
WES
I TEN
GA
H
SULA
WES
I SEL
ATA
N
SUM
ATE
RA
UTA
RA
PA
PU
A
KEP
. RIA
U
AC
EH
KA
LIM
AN
TAN
TEN
GA
H
SULA
WES
I UTA
RA
KA
LIM
AN
TAN
SEL
ATA
N
BEN
GK
ULU
KEP
. BA
NG
KA
BEL
ITU
NG
SULA
WES
I TEN
GG
AR
A
SULA
WES
I BA
RA
T
MA
LUK
U
MA
LUK
UU
TAR
A
PA
PU
AB
AR
AT
IND
ON
ESIA
21.0
Proportion of CEONC (Comprehensive Emergency Obstetric & Neonatal Care) Hospital
Sumber: Riset Fasilitas Kesehatan 2011
Email: [email protected]
10.5610.5810.71
13.4413.6113.7313.8714.0414.2914.3514.7714.8515.1115.3815.5715.85
16.7818.0318.64
19.4619.7420.19
21.8522.2222.8123.1423.30
24.1924.32
26.2426.32
33.7433.85
37.58
0 10 20 30 40 50 60 70 80 90
Maluku
Papua Barat
DKI Jakarta
Sumatera Utara
Papua
Kalimantan Barat
Bengkulu
Bangka Belitung
Kalimantan Selatan
Jawa Barat
Kalimantan Tengah
Maluku Utara
DI Aceh
Riau
Sulawesi Utara
Lampung
Sumatera Selatan
Sulawesi Tenggara
Indonesia
Sulawesi Selatan
Jawa Tengah
Kalimantan Timur
Nusa Tenggara Timur
Sulawesi Barat
Jambi
DI Yogyakarta
Banten
Sumatera Barat
Gorontalo
Jawa Timur
Bali
Sulawesi Tengah
Kepulauan Riau
Nusa Tenggara Barat
Proportion of BEONC (Basic Emergency Obstetric & Neonatal Care) Health Center
19Sumber: Riset Fasilitas Kesehatan 2011
Email: [email protected]
Health & Nutrition Status of Pregnant Women
Email: [email protected]
Pregnant women + hypertension, 2007
5.87.0
9.812.5
18.1
25.0
44.0
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Hip
ert
en
si (%
)
Umur Ibu hamil (Tahun)
Source: Riskesdas 2007
Email: [email protected]
Pregnant women + hypertension, 2013
6.3
3.1
0
1
2
3
4
5
6
7
Hypertension Diagnosed hypertension
Source: Riskesdas 2013
Email: [email protected]
Pregnant women + DM, 2007
0.500.45
0.36
0.50
0.73
1.64
0.52
0.00
0.40
0.80
1.20
1.60
2.00
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Dia
be
tes
(%
)
Umur Ibu Hamil
Source: Riskesdas 2007
Email: [email protected]
Pregnant women + Malaria, 2007
2.4 2.5 2.4 2.4
3.5
4.4
6.2
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Ma
lari
a (
%)
Umur Ibu hamil (tahun)
Source: Riskesdas 2007
Email: [email protected]
Proportion of Anemia in Pregnant Women by urban/rural, 2013
36.437.8 37.1
0.0
10.0
20.0
30.0
40.0
50.0
Perkotaan Perdesaan INDONESIA
*) Nilai rujukan menurut WHO/MNH/NHD/MNN/11.1,2011 dan Kemenkes,1999
**) Cut off points anemia Ibu Hamil, Hb < 11,0 g/dl
Email: [email protected]
Nutrition status of pregnant women, weight gain during pregnancy (kg)
Source: Cohort study on child growth & development, 2013
Email: [email protected]
Energy intake of pregnant women
87.5
42.4
70
44.4
67.2
51.8 50.1
67.2
45.3
79.2
47.5
71.2
80.1
69.865.2
0
20
40
60
80
100
120
< 20 20 - 24 25 - 29 30 - 34 ≥ 35
Trimester 1
Trimester 2
Trimester 3
Source: Cohort study on child growth & development, 2013
Email: [email protected]
67.2
39.234.2
50.1
30.5
46.9 44.8 48.1 49.4 49.8
70.2
48.456.9 58.2 55.8
0.0
20.0
40.0
60.0
80.0
100.0
120.0
< 20 20 - 24 25 - 29 30 - 34 ≥ 35
Trimester 1
Trimester 2
Trimester 3
Protein intake of pregnant women
Source: Cohort study on child growth & development, 2013
Email: [email protected]
Proportion of too young, too old, too close between pregnancies, too many children, 2013
0
10
20
30
40
Terlalu muda<20 tahun
Terlalu tua >35tahun
Terlalu dekat<2 tahun
Terlalu banyak>4 anak
8.412.1
33.7
7.1
Source: Riskesdas 2013
Email: [email protected]
Proportion reproductive women with risk of chronic malnourish : 2007 & 2013
31
.3
23
.8
16
.1
12
.7
12
.6
10
.3
5.6
30
.9
18
.2
13
.1
10
.2
8.9
7.9
8.1
0.0
10.0
20.0
30.0
40.0
50.0
15-19 20-24 25-29 30-34 35-39 40-44 45-49
2007
Hamil Tidak Hamil
38
.5
30
.1
20
.9
21
.4
17
.3
17
.6 20
.7
46
.6
30
.6
19
.3
13
.6
11
.3
10
.7
11
.8
0.0
10.0
20.0
30.0
40.0
50.0
15-19 20-24 25=29 30-34 35-39 40-44 45-49
2013
Hamil Tidak Hamil
Source: Riskesdas 2007 & 2013
Email: [email protected]
Pregnant women: weight gain vs height (N=220)
kg
2,4 kg
mgg
Tahun 2013: N = 220 ibu hamil**
9.0
10.310.7
9.1
7.3
-1.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
4 8 12 16 20 24 28 32 36 37 38 39 40
< 150 Cm ≥ 150 Cm IOM 2009
Source: Cohort study on child growth & development, 2013
Email: [email protected]
Pregnant women: weight gain vs body weight before pregnant
8.2
10.0
10.7
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
4 8 12 16 20 24 28 32 36 37 38 39 40
BBPH < 45 BBPH ≥ 45 kg IOM 2009
Source: Cohort study on child growth & development, 2013
Email: [email protected]
Other determinants
Email: [email protected]
Mother’s education vs
maternal health services, SDKI 2012
Pendidikan IbuPeriksa Hamil
dengan Nakes
Mendapat Pil
Zat Besi
Persalinan di
Faskes
Penolong
persalinan dg
Nakes
Kunjungan
Nifas (1-2 hari)
Tidak Sekolah 64.0 36.7 21.1 31.8 38.8
Tidak tamat SD 88.5 61.5 38.0 61.1 66.5
Tamat SD 94.0 70.4 47.1 72.8 75.9
Tidak Tamat SLTP 97.4 77.6 61.0 85.7 78.5
Tamat SLTP 98.4 80.0 79.8 94.3 86.9
SMTA+ 99.1 86.3 86.4 96.8 89.5
Source: Atmarita, 2013
Email: [email protected]
Economic status vs maternal health services, SDKI 2012
Status Ekonomi
Periksa
Hamil
dengan
Nakes
Mendapat Pil
Zat Besi
Persalinan di
Faskes
Penolong
persalinan dg
Nakes
Kunjungan
Nifas (1-2
hari)
Terbawah 86.9 61.6 29.7 57.5 59.3
Menengah Bawah 95.8 74.8 57.2 81.8 82.4
Menengah 97.7 77.5 66.2 89.7 83.5
Menengah Atas 99.0 79.5 79.1 93.2 85.3
Teratas 99.4 84.6 88.1 96.6 91.1
Source: Atmarita, 2013
Email: [email protected]
Total Fertility Rate: 1981-2012
4.3
3.3
3.022.85 2.78 2.6 2.6 2.6
3.7
2.82.6
2.31 2.4 2.4 2.32.4
4.5
3.6
3.243.15
2.98
2.7 2.8 2.8
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
1981-1983 1984-1987 1988-1991 1992-1994 1995-1997 1998-2002 2003-2007 2008-2012
TF
R
Reference Period
Kota+Desa
Kota
Desa
Source: IDHS 1991 - 2012
Email: [email protected]
Age of married status
Proporsi Remaja/Dewasa Muda Menurut Tempat Tinggal dan Status Kawin, Riskesdas 2010
Jenis Kelamin
Kelompok Umur
(Tahun)
Kota Desa
Belum Kawin
Kawin Belum Kawin
Kawin
Laki-laki
10-14 99,9 0,1 99,9 0,1
15-19 98,7 1,3 97,8 2,2
20-24 82,9 17,1 71,7 28,3
Perempuan
10-14 99,9 0,1 99,7 0,3
15-19 92,8 7,2 82,5 17,5
20-24 46,9 53,1 14,4 85,6
Email: [email protected]
Policy and Programs
Email: [email protected]
Maternal health care
• Stated as the priority in health development
• Crash program of midwife education posted midwife in each village
• Maternal health insurance (Jampersal), now integrated into National Health Insurance Scheme of Indonesia
• Increasing the role and capability of midwife: education & training
• Decreasing the role TBA (Traditional Birth Attendance)
Email: [email protected]
Maternal health care
• Increasing the BEONC Health Center• Increasing the CEONC Hospital• Improving the quality of services both in
Health Center and Hospital• Increasing the coverage of CPR
(Contraception prevalence rate)• Increasing the coverage of maternal
health services• Health promotion for mothers and
adolescents.
Email: [email protected]
Conclusion
Email: [email protected]
Conclusion
• MMR in Indonesia still high need work hard to decrease MMR
• Coverage of maternal health services is increasing
• Poor quality of health services improving quality of services is a must
• Health & Nutrition status of pregnant women not yet optimum need innovative action
• Multi-sector interventions should be done in very good coordination
Email: [email protected]
Thank youTerima kasih
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