INTERNATIONAL CONFERENCE ON CSR AND COMBATING MALNUTRITION:

OBTAINING MILLENNIUM DEVELOPMENT GOALS (MDGs) IN INDONESIA

Grand Sahid Jaya Hotel, 13 – 14 December 2010

Session 1: Prevention & Intervention in Improving The National

Nutrition Status in Indonesia

Budi Iman Santoso, Sp. O.G., Head of Obstetrics & Gynecology,

Cipto Mangunkusumo Hospital

EFFORTS OF OBSTETRIC CARE

ON REDUCING MATERNAL MORTALITY

RATE TO ACHIEVE MDG TARGETS

IN INDONESIA

Dr. Budi Iman Santoso, SpOG(K)

DEPARTMENT OF OBSTETRIC-GYNECOLOGY

CIPTO MANGUNKUSUMO HOSPITAL –

FACULTY OF MEDICINE UNIVERSITY OF INDONESIA -

JAKARTA

OUTLINE

Introduction

Achievement of Reduced MMR

Comprehensive analysis

◦ Linear and Dynamic System

◦ Priority Strategy – 5W + 1 H

Role of Obstetric Care

SWOT Analysis

Conclusion

INTRODUCTION

Millenium Development Goals (MDGs)

September, 2000 – the Millenium Summit of

189 UN Nations, the Millenium Declaration

Indonesia:

◦ The National Long-term Development Plan

RPJPN (2005-2025)

◦ Mid-term: RPJMN 2005-2009 & 2010-2014

◦ Annual: RKP

INTRODUCTION… MDGs

Pro-growth, pro-jobs, pro-poor and pro-environment

8 targets:

5A. Reduce MMR by three-quarters

between 1990-2015

5B. Achieve universal access to

reproductive health

THE CURRENT STATUS OF MDG TARGETS

3 categories of MDG achievement

A. Have already been achieved: 1,3,6

B. Significant progress has been achieved: 1,

2, 3, 4, 8

C. Still requires great efforts to be

achieved:

1,5,6,7

REDUCED MATERNAL MORTALITY RATE

IN INDONESIA

1992: 425/100.000

2007: 228/100.000

RJMPN 2014: 118

MDG 2015: 102

Acceleration initiatives!

Global: MDG 5 slow progress

◦ Only China and Vietnam have been “on track”

◦ Separating MDG 5A and 5B (introduced 2007)

Indicators of Achievement: MDG 5

Mostly, still need special

attention

Indonesia: We are not alone

– similar results in Asia

Pacific region

COMPREHENSIVE ANALYSIS

LINEAR SYSTEM OF THINKING

DYNAMIC SYSTEM

PRIORITY STRATEGY – 5 W + 1 H

LINEAR SYSTEM :

Gender, Nutrition, Safe Abortion

Pre-Pregnancy, Pregnancy, Labor & Delivery,

Post-Partum

Gender Issues- Reproductive Health:

Woman’s Basic Human Rights

Safe mother – Safe child

Mother’s nutrition - neglected

Dear man,

Do you really care for your woman & children??

Family Planning – Safe Abortion,

Woman’s right

Woman’s right is not only in Education and Work

But most importantly is the right to decide what’s best for her

body

DYNAMIC SYSTEM :

4 sub-systems:

◦ Demography, social and culture (blue)

◦ Family Planning (yellow)

◦ Quality of labor assistance (red)

◦ Environment and sanitation (grey)

PRIORITY STRATEGY 5W

+1H WHAT – 4 Priority Strategies, 1 Vision:

“Making Pregnancy Safer”

◦ Quality of Effective Health Services

◦ Inter-program/sector/private partnership

◦ Family empowerment

◦ Public Mobilization

WHERE – Extreme extensive area in

Indonesia Map of Priority for Target

Area

PRIORITY STRATEGY 5W

+1H WHO –

◦ Target: mother and couples of reproductive

age

◦ Executor: Health care professionals

Mutual responsibilities: government,

private & community

Need a Consultant Manager?

Role of general practitioner in assisting

labor (in service & pre-service)

PRIORITY STRATEGY 5W

+1H WHEN – tight deadline 2015

◦ When is the best time for monitoring & evaluation

◦ Improvement on indicator – Official / Alternative

indicator

WHY – clearly stated in linear & dynamic

system

HOW – Start the Effective Strategy ASAP

◦ Guidelines

◦ Meetings & panel discussion

Official or Alternative indicators?Asian-Pacific Resource &Research for Woman (ARROW)

THE ROLE OF OBSTETRIC CARE

Most maternal death is due to obstetric

complication and emergency

Risk of maternal death – extremely high:

◦ 100 x on First day after labor

◦ 30 x on Second day postpartum

◦ 14.8% - 1 week before labor

◦ 43.5% during labor

◦ 23.7% in 1 week after labor

Obstetric care has important role on Strategy 1

(Access and Quality Health Services)

Obstetric and neonatal emergency care

Preventive and promotive care:

◦ Pre-pregnancy (Family Planning, Pre-marital

counseling, Improved Nutrition, Immunization)

◦ During pregnancy (ANC, BPCR, Fe, Calcium (PE/E),

Immunization)

◦ During Labor (Labor assistance in Health Care

Facility, Safe and Clean Labor, CTG, Biophysical

profile, Partograf, MAK III, Initial breast feeding)

ROLE OF OBSTETRIC CARE

JNPK (Jaringan Nasional Pelatihan Klinik) & MOH

Directorate General of Medical Services have conducted

training on Comprehensive Emergency Obstetrics and

Neonatal Care (CEONC) at Tangerang Hospital (2008-

2009)

Training Results

20 hospital staff (3 obs-gyn, 2

pediatricians, 9 midwives, 6 nurses) are

certified in CEONC

4 Health Care units are certified in

BEONC

40 midwives are certified in LSS

Training results

Midterm Maternal Death reduced from 32/2998 to

12/3503 live-birth

Annual Maternal Death reduced from 52/5002 (2008)

to 29/7018 live-birth (2009).

Reduced Annual Mortality*

Mortality 2008 2009

Maternal

per 100,000 live-births800 300

Perinatal

per 1000 live-births30 16

Effective Obstetric Care

Cause of death Effective care % reduction

Bleeding AMTSL,Obstetric care,

transfusion

40%

Infection Preventing infection and

uses of antibiotics

13%

Eclampsia Magnesium Sulfate & anti

hypertension agents

7%

Delayed labor Partograf, Operator

competence

10%

ROLE OF OBSTETRIC CARE

Health care professionals have less role in

Strategy 2 (Inter-Program & Sector Partnership)

Rigid bureaucracy & regulation

Turniani L, et al: Strategic policy has supported

the program of reducing MMR

Sugeng et al: not all sectors have realized the

importance of program to reduce MMR

Program supported by local government policy

Province Supported Program

East Java APN, PONEK, AMP, PONED,

CAPACITY BUILD

South Kalimantan GSI, AMP, Bidan Siaga, MPS

North Sulawesi GSI, SPM, AMP

ROLE OF OBSTETRIC CARE

Least role in Strategy 3 (Family

Empowerment)

In Strategy 4 (Public Mobilization) it

depends on government initiatives to

involve the health care professionals

COULD WE ACHIEVE MDG 5 BY 2015??

SWOT analysis ON MDG 5 - 102/100,000 livebirth on 2015

STRENGTH

Fine human resource

Good strategy program

High commitment by the government,

private sectors (CSR)

Overseas fund: USAID for CEONC

Many programs have been conducted

Positive reduction on MMR, needs

acceleration

Weakness –

Different vision, not well-coordinated

Less concern on priority

Less awareness on woman’s right in

reproductive health

Geographical obstacles

Tight deadline

Problems in training of labor assistance

Opportunity –

Support by developed countries on MDG

program

Threat –

No concern on existing program

Egoism – fond of new program rather than

integrating with the existing program

CONCLUSION

Positive reduction in MMR needs acceleration

Issues on discussion:

◦ Gender equality / woman’s right: family planning, nutrition, safe

abortion

◦ Alternative indicators

◦ Effective Strategy

◦ Consultant manager

◦ Using technology : www. kesehatan-ibuanak.net Launching: 30

Nov 2010

◦ Training of labor assitance (in service dan pre-service)

◦ Fund rising

GREATEST THREAT:

WE DON’T CARE

I don’t care

REDUCING MMR

= Treating Wound Healing

At beginning… Everything looks terrible….

But … We Care !!(On courtesy of: Kompyang Rata, I Gusti Agung)

First month… After exhausting efforts of daily care..

Nearly loss of hope

But.. We do care!!!

Third month…. On Progress..

For the patient, it is still troublesome

But.. We still and do care !!

Fourth month… and there is a smile

120 x we’ve tried to be still and do care..

When it seems nothing…

Actually, there is everything…

Every dark cloud has a silver lining

Is it a road to DIE or to SMILE – We decide..