An Overview of Maternal and Child Health Status in Indonesia Meah Gao*

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1 An Overview of Maternal and Child Health Status in Indonesia Meah Gao* *Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada. Indonesia used to have one of the highest maternal and infant mortality rates in both the southeastern Asian region and globally. With efforts from the government and nongovernmental organizations (NGOs), the past two decades have witnessed considerable improvements in maternal and child health in Indonesia. Here, we examine the current status of maternal and child health in Indonesia and pertinent projects that aim to improve public health infrastructure, medical professional training, community awareness and participation led by both the government and NGOs. Indonesia, consisting of more than 17,000 islands with over 200 million inhabitants, is the second most populated country in the region and the fourth most populated country in the world. Over the past two decades, reform in Indonesia has led to significant decentralization, resulting in an unprecedented economic growth in the country. The public health profile in Indonesia has also improved considerably, shown as both an increase in the average life expectancy (67 years as of 2005) and a continuous decrease in the total fertility rate (2.6 as of 2003) 1. Maternal and child health has improved significantly in Indonesia as well, mostly reflected by the decrease in maternal mortality, infant mortality and under-5 mortality figures. This paper aims to look at the current state of maternal and child health in Indonesia, survey relevant programs and projects led by both Indonesian government as well as nongovernmental organizations (NGOs), assess their results and achievements, and lastly, comment on the prospect of Indonesian maternal childre health in the future. Status of Maternal Health Maternal health appears to be improving for women in Indonesia. Data from the 2000 Household Health Survey (HHS) indicated a maternal mortality rate (MMR) of 390 deaths per 100,000 live births, showing a steady decline since the mid 1980s (Figure 1) 1-2. However, a closer examination of the data revealed substantial variations in MMR between different regions. For instance, in Central Java, the MMR was estimated at 248, while in West Java it was 686. National data shows that 70.59% of births were attended by skilled health professionals, showing a continuous growth from previous years. This can be explained by the increase in both the number of skilled providers in the healthcare system as well as the tendency of using professional health workers by the general public 3-5.

2 it is estimated that 15-30% of the maternal mortality is attributed to unsafe abortion 1. Status of Infant Health and Under-Five Child Health Family planning in Indonesia has also shown considerable successes. Contraceptive use has more than tripled in 27 years, increasing from 19% in 1976 to over 54% in This has had impacts on several other fertility indicators: Total fertility rate (TFR) has decreased by more than 50% from 5.6 in 1968 to 2.6 births per woman in The age at first marriage for women has increased from 18.6 years in 1997 to 19.2 years in ,3. It can be speculated that the increased access to and use of contraceptive devices have contributed to the reduction in total fertility rate and the increase in age at first marriage by preventing child-bearing age females, in particular the teens, from unwanted pregnancies. Abortion is still illegal in Indonesia. As a result, it is often performed under unsafe conditions. An estimation of over 2.5 million abortions take place in Indonesia each year, and Health of children appears to be improving as shown by indicators such as the under-five mortality rate (U5MR) and the infant mortality rate (IMR) in Figure2 and 3 1. The major conditions affecting children s health are summarized in Table 1 and the common causes of neonatal deaths are illustrated in Figure 4. Low birthweight, asphyxia (primarily from choking),

3 tetanus and feeding problems remain the leading causes of neonatal deaths in Indonesia 3, 6-7. from 36.65% in 1995 to 24.6% in 1998 amongst child-bearing age women 8. Table 1. Disease-related infant mortality in Indonesia The Indonesia Expanded Program on Immunization recommends that all children receive vaccination against the six major preventable diseases: polio, measles, diphtheria, tetanus, pertussis and tuberculosis during their first year. Recent Indonesia Demographic and Health Survey shows that the distribution of Maternal and Child Health Handbook (MCH handbook) has effectively improved immunization coverage in Indonesia. In 2002/3, 70.9% of children who received MCH had received all vaccines, whereas only 42.9% of children who did not won record had been fully immunized. This increased immunization coverage could be a reflection of the growing awareness of immunization amongst community and children s parents through MCH handbook implementation Data also show that the nutritional status in children under-five has improved over the period According to data from National Social and Economic Survey, nutritional deficiencies among under-fives dropped from 39.2% in 1989 to 28.3% in At the same time, chronic energy deficency rate, a predictor of low birth weight, has declined Government initiatives: Public Health Infrastructure Building and Healthcare Professional Education Programs. Health service delivery in Indonesia is organized into five levels: central, provincial, districts, sub-districts and villages. Table 2 summarizes the basic facilities and responsibilities of each administrative level 1. The government s initiatives have been mostly focused on expanding primary care coverage on the village- and subdistrict levels. The current infrastructure from

4 2001 data includes 7,243 community health centers, 21,115 sub-health centers, and 243,783 integrated village health posts. Finally the Posyandu network, run by Family Welfare Movement, with more than 1.2 million volunteers, provides the basic community level health care and health knowledge 1,11. Table 2. Healthcare services in Indonesia The main health providers delivering maternal, newborn and child health services include doctors, both general and specialists, nurses and midwives. Midwives make up the largest proportion of staff at the village and subdistrict level health centers. Training of medical doctors is executed through medical schools located within universities. Nursing and midwifery training takes place mainly at specific schools for nursing or midwifery. All nurses and midwives follow a three- year diploma program. Recently, government has launched various programs to encourage trained midwives and nurses to work in remote rural regions and collaborate with the traditional birth attendants there 11. Non-Governmental Organization initiatives: Education and Family Planning. In addition to programs directed by Indonesian government, many NGOs have also funded projects aiming to improve maternal and child health in Indonesia. These projects often focus on improving community awareness and facilitating family planning services. For instance, USAID has its Health Services Program as its principle mechanisms for providing maternal and child health assistance. Its main activities aim to promote positive health practices at the community level, improve access to quality health services in both the public and private sectors and reduce mortality by programs covering birth preparedness, essential newborn care, early and exclusive breastfeeding, prevention of postpartum hemorrhage, management of diarrhea, and handwashing and hygiene habits 10. Similarly, the Asia Foundation recently completed its Family Planning Assistance Program in which contraceptive devices were dispersed to local people and information relating to reproductive issues was also provided to people in certain rural regions. Future Outlook Indisputably, Indonesia has witnessed dramatic health gains over the past two decades in

5 its maternal and child health. However, recent 4. Central Bureau of Statistics. Health statistics, surveys suggest that this improvement may be Jakarta: CBS, stagnating. While Indonesia more than halved child mortality between 1987 and 2002, it saw no 5. Central Bureau of Statistics. Profile of mother further significant reduction in child mortality and children health 2001, Jakarta: CBS between 2002 and Wide disparities in access to health care between urban and rural 6. National Health Survey. Mortality study populations, lack of financial access to services report 2001: Main causes of death in Indonesia. among the poor and weak government regulation Jakarta, on the quality of care delivered in the public and private sectors all contribute to this stagnation. 7. National Health Survey. SKRT reports 2001: Moving forward, Indonesia government needs to Morbidity and disability study. Jakarta, join force with non-governmental organizations in taking decisive and effective measures to 8. Jahari, A, Sandjaja, Sudima H, Jus at I, Jalal F, address the aforementioned issues, in order to Minarto. Nutritional Status of Underfives in further advance maternal and child health in Indonesia During the Period of (Draft). Indonesia. Jakarta: Ministry of Health, References 1. World Health Organization. Improving maternal, newborn and child health in south-east Asia region Osaki K, Hattori T, Kosen S and Singgih B. Investment in home-based maternal, newborn and child health records improves immunization coverage in Indonesia. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2009; 103: Ministry of Health. Indonesia health profile Jakarta: Ministry of Health, USAID. MCH program description, Indonesia Titaley CR, Dibley MJ, Agho K, Roberts CL and Hall J. Determinants of neonatal mortality in Indonesia. BMC Public Health Jul; 8: Ministry of Health. National health system. (National Draft August 2003). Jakarta: Ministry of Health, 2003.

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