2010年-世界发展银行全球_and_then_she_died___Indonesia_Maternal_Health_Assessment_88页_6mb

Summary of the Indonesia Maternal Health Assessment

Core Content

This document provides a comprehensive assessment of maternal health in Indonesia, focusing on the country's efforts to reduce maternal mortality, the current state of maternal health and mortality, the role of health providers and facilities, financial and insurance mechanisms, service utilization, and the effectiveness of existing policies and programs. It highlights the challenges and proposes future interventions to improve maternal health outcomes.

Main Points

Current Maternal Health and Mortality

• Maternal Mortality Ratio (MMR): The latest data from 2007 shows an MMR of 228 per 100,000 live births, which is still higher than the government's target of 102 by 2015.
• Skilled Birth Attendants: In 2007, 73% of births were attended by skilled providers (Ob-Gyns, doctors, nurses, or midwives), but this varies significantly by province, with Jakarta at 97% and Maluku at 33%.
• Causes of Death: Hemorrhage remains the leading cause of maternal death, accounting for 54% in South Kalimantan and 34% in West Sumatra. Infections and eclampsia are also significant contributors.
• Unsafe Abortions: These are a major cause of maternal mortality. Many are performed by unskilled providers in unsanitary conditions, with TBAs involved in up to 84% of rural abortions.
• Contraceptive Prevalence Rate (CPR): Stagnated at 61% since 2002, with pills and injectables making up 45% of contraceptive methods used. Long-term methods (implants, IUDs, sterilization) account for only 11%.
• Sociocultural Determinants: Economic status, education, and age at first marriage significantly influence maternal health outcomes and access to care. Wealthier women are more likely to access skilled care, while the poorest are not.

Government Response

• Health Policies: The government has focused on midwives and community-based interventions as central to maternal health strategies. However, these efforts have not been sufficient to reduce maternal mortality effectively.
• Programs and Initiatives:
  • Healthy Indonesia 2010: Aims to improve health outcomes, including maternal mortality.
  • Minimum Service Standards (MSS): Aims to standardize care across the system.
  • Making Pregnancy Safer (MPS): Focuses on birth preparedness and complication prevention.
  • Social Health Insurance (SHI): Includes Jamkesmas, which aims to provide coverage to the poor but has only reached 76.4 million people out of an estimated 104 million eligible.
• Human Resource Gaps: Midwives and doctors are underutilized for normal delivery and maternal health, respectively. Many midwives lack the necessary skills to manage complications.
• Emergency Obstetric Care (EOC): Not widely available, especially for poor women, and hospitals often fail to implement standard EOC policies.

Service Utilization

• Continuum of Care: Despite progress, the system still lacks effective integration between community and hospital services.
• Antenatal Care (ANC): Almost universal, but not sufficient to reduce maternal mortality.
• Use of Skilled Providers: While skilled providers are more common in wealthier areas, access remains uneven. The poorest women are least likely to receive skilled care.
• Cesarean Sections (C-Sections): Usage is low and uneven, with significant variation by region and education level.
• Referral Systems: Often inefficient, leading to delays in treatment and poor outcomes for women in need of emergency care.

Information Systems

• Reporting and Recording: Inconsistent and incomplete, making it difficult to accurately assess maternal health outcomes.
• Vital Registration: Limited, especially in rural areas, which affects the reliability of mortality data.

Key Recommendations

• Expand the Role of Doctors and Nurses: Address the underutilization of doctors and nurses in maternal health.
• Improve Emergency Obstetric Care: Enhance availability and implementation of EOC in public hospitals.
• Strengthen Referral Systems: Improve coordination between community and hospital services to ensure timely and effective care.
• Standardize Care Quality: Implement accreditation and certification to ensure quality across all providers and facilities.
• Enhance Utilization of Health Insurance: Develop incentives for providers to serve the poor and improve program access for eligible clients.

Conclusion

The Indonesian maternal health system has made progress in increasing the use of skilled birth attendants and expanding access to antenatal care. However, these efforts are not enough to significantly reduce maternal mortality. The system is characterized by uneven access, poor quality of care, and ineffective referral mechanisms. Addressing these issues requires a more comprehensive approach, including the better utilization of doctors and nurses, improved emergency care, and stronger integration of community and hospital services. Additionally, there is a need for better data collection, standardization of care, and enhanced support for the poor through social health insurance.

Key Information

• MMR (2007): 228 per 100,000 live births.
• Skilled Birth Attendants (2007): 73% of births attended by skilled providers.
• Jamkesmas Coverage: Only 76.4 million out of an estimated 104 million eligible people are covered.
• Unsafe Abortions: Estimated between 700,000 and 3 million annually, with TBAs involved in up to 84% of rural cases.
• CPR (2007): 61%, with pills and injectables being the most commonly used methods.
• Wealth Disparities: 70% of wealthiest women give birth with a health professional, while only 10% of the poorest do.
• Legal Challenges: Ambiguous abortion laws hinder access for single women and contribute to unsafe procedures.

Key Acronyms and Abbreviations