Nutrition, Health Status, Programs and Policy for Pregnant ... fileCause of Maternal Mortality...

Email: trihono1954@yahoo.com

Nutrition, Health Status, Programs and Policy for

Pregnant and Lactating Women in Indonesia

TrihonoSenior Health Advisor

Jakarta, 12 August 2014

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

Maternal Mortality Ratioin Indonesia

Source: Prof. Terence H Hull

MMR 1994 - 2012

334307

1989-1994 1993-1997 1998-2002 2003-2007 2008-2012

Reference Period

Source: IDHS 1994 - 2012

Email: trihono1954@yahoo.comSource: IDHS 1994 - 2012

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,

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-

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

16.4 16.8 28.1 26.3 29.8 20.3

O20-O29, O60-

O63, O67-O71,

O73-O75, O81-

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)

(N=3334)

(N=587)

(N=979)

(N=887)

(N=7524)

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

Place of Maternal Death

Government Hospital

Private Hospital

Others

Source: Follow up study of maternal mortality of PC 2010

Coverage ofMaternal Health Services

Coverage of ANC, 1991 - 2012

1991 1994 1997 2002 2007 2012

55.163.1

70.481.0 81.5

Reference period

Coverage of ANC-4 by Provinces, 2010 - 2013

2010 2013

Source: Riskesdas 2010 - 2013

Coverage of SBA: 2010 - 2013

2010 2013

Coverage of PNC: 2010 - 2013

2010 2013

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

Quality of Maternal Health Services

Proportion of CEONC (Comprehensive Emergency Obstetric & Neonatal Care) Hospital

Sumber: Riset Fasilitas Kesehatan 2011

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

0 10 20 30 40 50 60 70 80 90

Maluku

Papua Barat

DKI Jakarta

Sumatera Utara

Kalimantan Barat

Bengkulu

Bangka Belitung

Kalimantan Selatan

Jawa Barat

Kalimantan Tengah

Maluku Utara

DI Aceh

Sulawesi Utara

Lampung

Sumatera Selatan

Sulawesi Tenggara

Indonesia

Sulawesi Selatan

Jawa Tengah

Kalimantan Timur

Nusa Tenggara Timur

Sulawesi Barat

DI Yogyakarta

Banten

Sumatera Barat

Gorontalo

Jawa Timur

Sulawesi Tengah

Kepulauan Riau

Nusa Tenggara Barat

Proportion of BEONC (Basic Emergency Obstetric & Neonatal Care) Health Center

19Sumber: Riset Fasilitas Kesehatan 2011

Health & Nutrition Status of Pregnant Women

Pregnant women + hypertension, 2007

5.87.0

9.812.5

15-19 20-24 25-29 30-34 35-39 40-44 45-49

Umur Ibu hamil (Tahun)

Source: Riskesdas 2007

Pregnant women + hypertension, 2013

Hypertension Diagnosed hypertension

Pregnant women + DM, 2007

0.500.45

15-19 20-24 25-29 30-34 35-39 40-44 45-49

Umur Ibu Hamil

Pregnant women + Malaria, 2007

2.4 2.5 2.4 2.4

15-19 20-24 25-29 30-34 35-39 40-44 45-49

Umur Ibu hamil (tahun)

Proportion of Anemia in Pregnant Women by urban/rural, 2013

36.437.8 37.1

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

Nutrition status of pregnant women, weight gain during pregnancy (kg)

Source: Cohort study on child growth & development, 2013

Energy intake of pregnant women

51.8 50.1

69.865.2

< 20 20 - 24 25 - 29 30 - 34 ≥ 35

Trimester 1

Trimester 2

Trimester 3

39.234.2

46.9 44.8 48.1 49.4 49.8

48.456.9 58.2 55.8

< 20 20 - 24 25 - 29 30 - 34 ≥ 35

Trimester 1

Trimester 2

Trimester 3

Protein intake of pregnant women

Proportion of too young, too old, too close between pregnancies, too many children, 2013

Terlalu muda<20 tahun

Terlalu tua >35tahun

Terlalu dekat<2 tahun

Terlalu banyak>4 anak

8.412.1

Proportion reproductive women with risk of chronic malnourish : 2007 & 2013

15-19 20-24 25-29 30-34 35-39 40-44 45-49

Hamil Tidak Hamil

15-19 20-24 25=29 30-34 35-39 40-44 45-49

Hamil Tidak Hamil

Source: Riskesdas 2007 & 2013

Pregnant women: weight gain vs height (N=220)

2,4 kg

Tahun 2013: N = 220 ibu hamil**

10.310.7

4 8 12 16 20 24 28 32 36 37 38 39 40

< 150 Cm ≥ 150 Cm IOM 2009

Pregnant women: weight gain vs body weight before pregnant

4 8 12 16 20 24 28 32 36 37 38 39 40

BBPH < 45 BBPH ≥ 45 kg IOM 2009

Other determinants

Mother’s education vs

maternal health services, SDKI 2012

Pendidikan IbuPeriksa Hamil

dengan Nakes

Mendapat Pil

Zat Besi

Persalinan di

Faskes

Penolong

persalinan dg

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

Economic status vs maternal health services, SDKI 2012

Status Ekonomi

Periksa

dengan

Mendapat Pil

Zat Besi

Persalinan di

Faskes

Penolong

persalinan dg

Kunjungan

Nifas (1-2

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

Total Fertility Rate: 1981-2012

3.022.85 2.78 2.6 2.6 2.6

2.82.6

2.31 2.4 2.4 2.32.4

3.243.15

2.7 2.8 2.8

1981-1983 1984-1987 1988-1991 1992-1994 1995-1997 1998-2002 2003-2007 2008-2012

Reference Period

Kota+Desa

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

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

Policy and Programs

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)

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.

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

Thank youTerima kasih

Nutrition, Health Status, Programs and Policy for Pregnant ... fileCause of Maternal Mortality...

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