Maternal, Infant, and Young Child Nutrition and Nutrition ... · GAIN Global Alliance for Improved Nutrition . IDHS Indonesia Demographic Health Survey . IMA Interfaith Medical Assistance

Maternal, Infant, and Young Child Nutrition and Nutrition-Sensitive Practices In IndonesiaDESK REVIEWMarch 2018

Acronyms

BMI Body Mass Index BMS Breastmilk Substitutes CBR Community-Based Rehabilitation CRVS Civil Registration and Vital Statistics CCT Conditional Cash Transfer EAR Estimated Average Requirements ECD Early Childhood Development ENT East Nusa Tenggara FHR Fetal Heart Rate GAIN Global Alliance for Improved Nutrition IDHS Indonesia Demographic Health Survey IMA Interfaith Medical Assistance IPC Interpersonal Communication IYCF Infant and Young Child Feeding JKN Jaminan Kesehatan Nasional LBW Low Birthweight MCA Millennium Challenge Account MCH Maternal and Child Health MIYCN Maternal, Infant and Young Child Nutrition MMN Multiple Micronutrients MoH Ministry of Health MUAC Mid-Upper Arm Circumference NGO Non-Government Organization NMR Neonatal Mortality Rate NNCC National Nutrition Communication Campaign PKH Program Keluarga Harapan PSA Public Service Announcement RDA Recommended Daily Amount SEM Structured Equation Modeling SES Socioeconomic Status TBA Traditional Birth Attendant UNICEF United Nations Children’s Fund UNU United Nations University WASH Water, Sanitation, and Hygiene WHO World Health Organization WNT West Nusa Tenggara

Contents Contents .................................................................................................................................................. 2 List of Figures .......................................................................................................................................... 4 List of Tables ........................................................................................................................................... 4 Acknowledgements ................................................................................................................................. 5 1. Introduction .................................................................................................................................... 6 2. Methodology................................................................................................................................... 8 3. Findings ......................................................................................................................................... 10

3.1. Key MICYN Indicators in Indonesia 10 3.2. Women’s Empowerment, Decision-making, and Education 11 3.3. Maternal Health and Nutrition 12

3.3.1. Antenatal Care and Nutrition ........................................................................................ 12 ANC Prevalence and Coverage .................................................................................................. 12 ANC Determinants .................................................................................................................... 14 Antenatal Nutrition and Micronutrient Coverage .................................................................... 14 ANC Influencers......................................................................................................................... 19

3.3.2. Birth Practices ............................................................................................................... 19 Birth Registration ...................................................................................................................... 20 Facility-Assisted Births .............................................................................................................. 20 Health Personnel-Assisted Births .............................................................................................. 21

Barriers to Health Personnel-Assisted Births ........................................................................ 21 3.3.3. Postnatal Maternal and Newborn Care Practices ......................................................... 22

Postnatal Care Prevalence and Coverage ................................................................................. 22 Barriers to Postnatal Care ..................................................................................................... 23 Postnatal Nutrition Coverage and Cultural Practices ........................................................... 24

3.4. Neonatal and Child Health 24 Neonatal Health Prevalence and Coverage .............................................................................. 24

Low Birthweight .................................................................................................................... 25 Barriers to Neonatal Health ...................................................................................................... 26

3.5. Experiences and Challenges with Health Service Delivery (check place) 27 Overview of Indonesian Health System .................................................................................... 27 Barriers to Care ......................................................................................................................... 28

Poor availability of care ......................................................................................................... 28 Poor quality of care ............................................................................................................... 28 Gender .................................................................................................................................. 29 Financial constraints ............................................................................................................. 30 Remoteness and geography .................................................................................................. 30

Overcoming barriers to care ..................................................................................................... 30 3.6. Breastfeeding 30

Breastfeeding Overview ............................................................................................................ 30 Early Initiation of Breastfeeding ............................................................................................... 31 Exclusive Breastfeeding ............................................................................................................ 33 Barriers to Exclusive Breastfeeding .......................................................................................... 34 Continued Breastfeeding .......................................................................................................... 36

Breastmilk Substitutes (BMS).................................................................................................... 36 Manufacturers and Distributors of BMS and Related Legislation ........................................ 37

3.7. Complementary Feeding — Children 6–23 Months 40 Complementary Feeding Overview .......................................................................................... 40 Early Complementary Feeding .................................................................................................. 41

Early Complementary Feeding Prevalence and Coverage .................................................... 41 Determinants of Early Complementary Feeding ...................................................................... 43 Diet Diversity and Meal Frequency ........................................................................................... 43

Diet Diversity and Meal Frequency Prevalence and Coverage ............................................. 43 Diet Diversity and Meal Frequency Social Norms ................................................................. 45

Feeding During and After Illness and Addressing Poor Appetite .............................................. 45 3.8. Child Nutrient Intake 46

Nutrient Requirement Overview .............................................................................................. 46 Vitamin A Intake among Children ............................................................................................. 46 Iron Intake among Children ...................................................................................................... 47 Zinc Intake among Children ...................................................................................................... 47 Macronutrients and Energy Intake among Children................................................................. 48

3.9. Nutrition-Sensitive Practices 48 Water, Sanitation, and Hygiene (WASH) Practices ................................................................... 48

WASH Overview .................................................................................................................... 48 Effectiveness of WASH on Nutrition ..................................................................................... 49 Food Hygiene and Safety ...................................................................................................... 49 Handwashing at Critical Times .............................................................................................. 50 Sanitation .............................................................................................................................. 51

Early Childhood Development and Community Practices ........................................................ 52 Programs to Address Early Childhood Development ............................................................ 53

3.10. Recent MIYCN Formative Research and National Nutrition Communication Campaign in Indonesia 54

IMA World Health Formative Research and NNCC Campaign (2015-2018) ............................. 54 Objective ............................................................................................................................... 54 Methods ................................................................................................................................ 55 Results ................................................................................................................................... 55 Research Limitations ............................................................................................................. 56 National Nutrition Communication Campaign (NNCC) Overview......................................... 56 Public Service Announcement Understanding ..................................................................... 57

GAIN Formative Research – The “Baduta Project” (2013) ........................................................ 60 Objective and Methods ......................................................................................................... 60 Results ................................................................................................................................... 60 Limitations ............................................................................................................................. 61

4. Conclusions ................................................................................................................................... 61 5. Appendices.................................................................................................................................... 62

List of Figures

Figure 1. Under-five stunting in Indonesia by province .......................................................................... 6 Figure 2. Provinces with stunting prevalences categorized as “very high” or above 40 percent and their prevalences (%), 2013 .................................................................................................................... 7 Figure 3. Selected Provincial coverage of key maternal indicators as compared to national average, Indonesia 2015 ...................................................................................................................................... 13 Figure 4. Number of days women took iron folate tablet or syrup during pregnancy of last birth, Indonesia 2012 ...................................................................................................................................... 17 Figure 5. Neonatal, infant, and under-five mortality rates per 1,000 live births in Indonesia between 1991 and 2017 ...................................................................................................................................... 25 Figure 6. Percentage of LBW babies born LBW or smaller than average by mother's education, Indonesia 2012 ...................................................................................................................................... 26 Figure 7. Coverage of exclusive breastfeeding on 0-5-month-old infants by province, 2015 .............. 33 Figure 8. Infant feeding practices by age, 2012. ................................................................................... 41 Figure 9. MCA Indonesia NNCC Campaign "Active Feeding" PSA Understanding ................................ 58 Figure 10. MCA Indonesia NNCC Campaign "Sanitation" PSA Understanding…………………………………..59

List of Tables Table 1. Indonesia stunting prevalence by gender, residence, and wealth quintile………………………….8 Table 2. Maternal, infant, young child nutrition indicators for Indonesia……………………………………….10 Table 3. Percentage of female highest educational attainment aged 15 years and older, Indonesia, 2012……………………………………………………………………………………………………………………………………………….13 Table 4. Mean MUAC (cm) of pregnant women age 15-25, Indonesia, 2013…………………………………..15 Table 5. Foods restrictions during and after pregnancy for women based on cultural beliefs, by province………………………………………………………………………………………………………………………………………….18 Table 6. Provinces that failed to meet 2015 Strategic Plan Target for 75% coverage of facility-assisted births, Indonesia, 2015……………………………………………………………………………………………………………………20 Table 7. Provinces that failed to meet 2015 Strategic Plan Target for the timing of the first neonatal visit, Indonesia, 2015………………………………………………………………………………………………………………………23 Table 8. Ration of health centers and hospitals per population, 2015…………………………………………… 28 Table 9. Key findings on high returns in investing in policies and programs to promote breastfeeding in Indonesia…………………………………………………………………………………………………………………………………...32 Table 10. Percentage of youngest children under age 2 by type of foods consumed according to breastfeeding status and age in Indonesia……………………………………………………………………………………..42 Table 11. Percentage of youngest children age 6-23 months living with their mother who are fed at least four key food groups, as defined by the MoH, in low performing Indonesia provinces, 2012…43 Table 12. Percentage of youngest children age 6-23 months living with their mother who are fed the minimum meal frequency, as defined by the MoH, in low performing Indonesia provinces, 2012….44 Table 13. Key findings of formative research conducted by MCA Indonesia to inform the NNCC…….56

Acknowledgements This desk review was prepared by Ms. Alexis Hoyt, Mr. Tom Grey, and Dr. Christina Wong, Alive & Thrive, FHI 360.

We would like to express our deep gratitude to Ms. Pearl Ang, Dr. Paul Zambrano, Mr. Roger Mathisen, Mr. Fernando Garcia, Ms. Mien Nguyen (Alive & Thrive, FHI 360); Dr. Jee Hyun Rah, Ms. Sri Sukotjo (UNICEF Indonesia); Ms. Claudia Rokx and Ms. Elviyanti Martini (The World Bank) for their valuable review, input, and guidance. Our appreciation also goes to Ms. Farah Amini (Millennium Challenge Account-Indonesia) and Mr. Iwan Hasan (IMA World Health) for sharing documents with us. This desk review was made possible by funding from the Bill & Melinda Gates Foundation.

Cover photo credit: Alison Hoover | Alive & Thrive.

DESK REVIEW: MIYCN AND NUTRITION-SENSITIVE PRACTICES IN INDONESIA 6

1. Introduction The effects of stunting and chronic malnutrition are highly consequential. Stunting is defined as height for length for age more than two standard deviations below the global median, according to World Health Organization (WHO) standards. The most crucial time to meet a child’s nutritional requirements is in the first 1,000 days, from conception to approximately two years of age. When these requirements are not met, stunting occurs.

Children who are undernourished in this period are at an increased risk of mortality, illness, infection, and delayed physical and cognitive development. Over time, stunting impacts a child’s future by impairing brain development, reducing educational achievement, and increasing the risk of poverty as they grow older. Global evidence suggests that the damage from stunting is largely irreversible, and catch-up growth is minimal. These imparities caused by stunting can contribute to poorer school performance, fewer years in school, and when seen on a national scale, they adversely affect a country’s development and growth (UNICEF, 2013).

While Indonesia has made significant strides in the past 10 years related to maternal, infant, and young child nutrition (MIYCN), difficulties remain, particularly related to stunting. As of 2013, 8.4 million (37.2 percent) Indonesian children under five were stunted. More recent estimates indicate that Indonesia’s prevalence of under-five stunting is up to 9 million (RISKESDAS, 2013; World Bank, 2015). No progress in stunting reduction occurred between 2007 (36.8 percent) and 2013 (37.2 percent), and stunting reductions have stagnated since decentralization in 2001 (World Food Programme, 2014).

This puts Indonesia’s prevalence of under-five stunting among the highest in Southeast Asia, second only to Laos (at 44 percent) (Global Nutrition Report, 2017). According to global data from UNICEF, Indonesia has the fifth highest absolute under-five stunting, behind China, Pakistan, Nigeria, and India (UNICEF, 2013). While Indonesia’s malnutrition response has succeeded in reducing the number of children categorized as underweight to approximately five percent, the country has fallen short of the Government of Indonesia’s goal of reducing stunting to 32 percent by 2015, which was the target set in the national mid-term development plan.

Figure 1. Under-five stunting in Indonesia by province

Source: World Food Programme, 2014


Recent research indicates that children who have a safe and clean environment, access to health services, adequate health care, and food-secure households, have a significantly lower risk of being stunted (Kim, 2017). Based on World Health Assembly Targets for 2025, Indonesia is off course with some progress related to these determinants to under-five stunting.

Because malnutrition response in Indonesia previously focused on reducing the number of young children who were severely underweight, programmatic and financial resources have unintendedly neglected stunting, possibly due to a failure to recognize its significance. Formative research conducted by IMA World Health (2018) in partnership with the University of Indonesia’s Center for Nutrition and Health Studies concluded that most people, even health workers, were not aware of stunting as a public health problem. Data collected from 11 districts in 10 provinces indicated that stunting was perceived as simply having short stature, and it was believed to be caused by heredity rather than environment. Only 20 percent of respondents—which included pregnant women, mothers of children under 2 years, family members, health workers, informal leaders, and district officials—recognized any negative association related to short stature. This national picture on stunting, however, does not accurately represent the disparities in stunting and issues related to MIYCN across Indonesia. The following 15 provinces have stunting prevalences categorized as “very high” or above 40 percent by the WHO (2010): Nusa Tenggara Timur, West Sulawesi, Nusa Tenggara Barat, West Papua, South Kalimantan, Lampung, South-East Sulawesi, North Sumatera, Aceh, Central Kalimantan, North Maluku, Central Sulawesi, South Sulawesi and Maluku (Figures 1 and 2). A full list of provinces with their stunting prevalences are included in Appendix 2.

Figure 2. Provinces with stunting prevalences categorized as “very high” or above 40 percent and their prevalences (%), 2013

Source: RISKESDAS 2013

Indonesia is a country with significant cultural, ethnic, and linguistic diversity. Often, urban-rural and socioeconomic differences are more important determinants of MIYCN status. Over 50 percent of the nation’s poor live on the island of Java, but the islands of Maluku and Papua, two of the most isolated and rural islands, consistently have the poorest MIYCN indicators. Even among the wealthiest households, 29 percent of children were stunted across Indonesia in 2013 (RISKEDAS, 2013). While malnutrition is prevalent across the country, it is worst in areas with limited infrastructure and access to schools, markets, and hospitals. Households reliant on subsistence

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East Nusa TenggaraWest Sulawesi

West Nusa TenggaraWest Papua

South KalimantanLampung

North SumateraAceh

Central KalimantanCentral Sulawesi

Sulawesi TenggaraMaluku Utara

South SulawesiMaluku

Papua


farming, those living in slums, or those with poor sanitation have the highest prevalence of malnutrition (RISKEDAS, 2013). This, coupled with geographically isolated terrain, amplifies disparities in health, especially among poor and rural populations. With approximately half of its population living in rural areas, it is important to begin to close these gaps in ways that are feasible and culturally relevant (United Nations, 2017).

The incentives to invest in MIYCN go beyond the human cost. This includes direct costs, such as an increased burden on the healthcare system, and indirect costs from lost productivity. It is estimated that for every U.S. dollar invested in nutrition programs, the Indonesian economy will reap forty-eight dollars back through improved productivity and lowered health care costs. As of 2014, malnutrition cost Indonesia more than US$5 billion in GDP annually. The World Bank (2011) estimates that Indonesia loses over US$2.6 billion in gross domestic product (GDP) due to vitamin and mineral deficiencies. However, this burden can be reduced significantly through targeted health and behavioral strategies. Investing in nutrition in Indonesia is crucial for the country’s development, not only for the reduction of child mortality and illness, but for the improvement of secondary health indicators such as school performance and educational attainment, resulting in greater national economic productivity (Chaparro, Oot & Sethuraman, 2014).

This desk review summarizes existing literature on MIYCN practices in Indonesia, focusing on the first 1,000 days nutritional window of opportunity. This includes identification of knowledge gaps that require further investigation to better explore barriers and facilitators towards optimal MIYCN practices and determine the best strategies to reach different target audiences. This desk review is guided by the framework for actions to achieve optimum fetal and child nutrition and development which was used to guide The Lancet’s maternal and child nutrition series (Appendix 1) (Black et al., 2013). The review also includes an analysis of existing communication products from previous and ongoing campaigns related to stunting and its determinants. The findings of this desk review can be used to support the development of social and behavior change communication (SBCC) strategies for stunting reduction, and knowledge gaps are identified for further research.

2. Methodology A review of relevant literature on MIYCN in Indonesia—including research documents, reports, policy notes, surveys, manuscripts, and communication materials—was carried out to gather necessary data. PubMed, Google Scholar, and Popline were used to identify relevant literature. Only sources from the past ten years were included in the search. The following search terms were used:

(“iron-rich foods” OR “iron-fortified foods” OR maternal nutrition OR “iron supplementation” OR anemia OR “vitamin A supplementation” OR underweight OR infant nutritional physiological phenomena[Mesh] OR breast feeding OR "infant feeding" OR “bottle feeding” OR “pre-lacteal feeding” OR complementary feeding OR

Table 1. Indonesia stunting prevalence by gender, residence, and wealth quintile

Background Characteristics Prevalence (%)

Gender Female children under-five (2013) 36.2 Male children under-five (2013) 38.1

Residence Urban (2010) 31 Rural (2010) 40

Wealth Quintile Lowest (2013) 48 Second (2013) 42 Middle (2013) 39 Fourth (2013) 32 Highest (2013) 29

Source: The Double Burden of Malnutrition Report. The World Bank, 2013; UNICEF Nutrition Report, 2013; RISKESDAS, 2013


supplementary feeding OR “breastmilk substitutes” OR stunting OR ((health knowledge, attitudes, practice[Mesh] OR KAP OR "knowledge, attitudes and practice") AND "infant feeding") OR (“feeding behavior” AND infant)) AND Indonesia

("infant nutrition" OR "breast feeding" OR "infant feeding" OR "bottle feeding" OR “pre-lacteal feeding” OR (frequency AND "milk feeding") OR "complementary feeding" OR "supplementary feeding" OR “breastmilk substitutes” OR "iron-rich foods" OR "iron-fortified foods" OR stunting OR "maternal nutrition" OR "iron supplementation" OR anemia OR "vitamin A supplementation" OR underweight OR malnutrition OR ((knowledge OR attitudes OR KAP OR "knowledge, attitudes and practice" OR behavior OR (nutrition AND WASH)) AND "infant feeding")) OR (“feeding behavior” AND infant)

Results of interest were then exported into EndNote X7, where they were then separated into subgroups, based on their topic. A separate folder was designated for those articles deemed ineligible if they did not meet inclusion criteria. These subgroups included:

• Antenatal care, nutrition, birth practices, and postnatal care • Breastfeeding • Child nutrition • Complementary feeding • Early childhood Interventions • General maternal and child health • General nutrition • Health services • Water, sanitation, and hygiene

In total, 411 sources were included, including grey literature. Literature were also received from UNICEF and The World Bank and were incorporated as they related to key facts and figures on MIYCN, MCH, and related disparities, WASH, programming in early childhood development and the Program Keluarga Harapan. Next, researchers went through each subgroup and identified those sources that met inclusion criteria for the review. Inclusion criteria included sources from the last ten years pertaining to Indonesia, whose research covered one of the subgroups mentioned above. Both country-level and region-specific sources were included. These sources were put into an Excel spreadsheet that was used to further organize the characteristics of each study of interest. A total of 146 published and 59 grey literature sources were included in this final list. These sources were then used to synthesize findings for this review. Additional sources were added as gaps emerged from the literature initially searched. Geographic, ethnic, and other differences related to these practices are specified and reported as they emerged in the data. Additional searches were conducted in accordance with direction from the Alive & Thrive team. These additions are reflected in the total source list, but they were not added to the Excel sheet used during the initial search. Research gaps for the forthcoming topics were identified based on findings from the review, as well as evidence from the literature and interventions across Indonesia. Major MIYCN indicators were extracted from the 2017 Indonesia Demographic Health Survey (IDHS) preliminary key indicator report, 2012 IDHS, 2013 Basic Health Research (RISKESDAS), and 2015 SUSENAS. The 2015 Indonesia Health Profile was used to augment data from the above surveys.


3. Findings

3.1. Key MICYN Indicators in Indonesia Table 2. Maternal, infant, young child nutrition indicators for Indonesia

Indicators for Indonesia Women’s empowerment

Female landowners (age 15-49) 41.0% Female home owners (age 15-49) 49.6% Median age of first marriage (age 25-49) 20.4 years Education level

No education 8.1% Elementary school drop-out 13.5% Elementary school/equivalent 27.9% Junior high school/equivalent 20.1% Senior high school/equivalent 21.8% Higher education 7.9%

Literacy 93.0% % Children under 5 years of age suffering from:

Underweight 5.0% Stunting 37.2% Wasting 13.3% Overweight 14.0%

Breastfeeding indicators Early initiation of breastfeeding 49.3% Exclusive breastfeeding 0-5 months 51.5% Predominant breastfeeding 0-5 months 49.0% Continued breastfeeding at 1 year old 77.0% Continued breastfeeding at 2 years old 55.0% Children ever breastfed 95.8% Mean duration of exclusive breastfeeding 3.7 months Mean duration of any breastfeeding 20.5 months Prelacteal feeding 60.0% Bottle feeding (0-23 months) 37.0% Milk feeding frequency of non-breastfed children (6-23 months) 18.3%

Complementary feeding indicators Introduction of solid, semi-solid or soft foods (all children, 6-8 months) 91.0% Minimum meal frequency (all children,6-23 months) 66.1% Minimum acceptable diet 58.2% Minimum dietary diversity 58.2% Consumption of iron-rich or iron-fortified foods 68.0% Consumption of vitamin A rich foods 82.7% Vitamin A supplementation in past 6 months (6-59 months) 83.5%

Maternal health and nutrition indicators Stunting of reproductive-age women 25.0% Women using modern contraceptive methods 57.2% Adolescent pregnancy 10.0% Fertility rate 2.3 children Maternal mortality ratio 1 in 210 Prevalence of undernutrition among pregnant women 24.2% Births attended by skilled health personnel 88.6% Deliveries in health facility 79% Post-natal care for mothers within 2 days of delivery 31.0% ≥90 iron pills taken during pregnancy 33% Anemia among pregnant women 37.1% Vitamin A deficiency among pregnant women 10.0 %


Postnatal vitamin A 48.1% Antenatal care coverage - at least four times 87.5%

Child health Overall under-five mortality 32 per 1,000 live births Neonatal mortality 15 per 1,000 live births Infant mortality 24 per 1,000 live births Newborns that are low birthweight 10.2%

WASH indicators Households using improved drinking water sources 87% Households using improved sanitation 61% Households using soap and water 92% Households with private toilets 68%

All data is from the 2017 IDHS report preliminary key indicator report, 2013 RISKESDAS or 2012 IDHS.

3.2. Women’s Empowerment, Decision-making, and Education According to the 2012 IDHS, employment, particularly for cash, control over earnings, and ownership of assets and land are important indicators for women’s empowerment, which in turn contributes to overall health. More than 6 in 10 married women and virtually all married men were employed in the past 12 months. Approximately 73.5 percent of employed women are paid in cash, in-kind, or a combination of both, compared to over 90 percent of men. However, roughly a quarter of employed women who work are not paid, including those who work on personal farms and in family businesses (Statistics Indonesia, 2012). The vast majority of currently married women with cash earnings mainly decide alone (65 percent) or jointly (29 percent) with their husbands how the money will be spent, and most currently married women whose husbands have cash earnings say the women mainly decide (41 percent) or decide jointly (46 percent) how his earnings are used. Just under half of all women age 15-49 own a house and 41 percent of women own land, with the majority sharing ownership with someone else. These indicators are similar across wealth quintiles. More than 8 in 10 currently married women participate in decisions about their own health care, major household decisions, and visits to their family or relatives (Statistics Indonesia, 2012).

The median age at first marriage among all women age 25-49 is 20.4 years. In general, urban women age 25-49 marry more than two years later than rural women (21.5 years compared with 19.1 years). A positive association is seen between median age at first marriage and level of education. For example, the median age at first marriage among women age 25-49 with completed secondary education is 22.9 years, which is more than five years later than women with no education (17.2 years). Also, women in wealthier households marry later than women in poorer households; the median age at first marriage for women age 25-49 in the highest wealth quintile is 22.6 years, compared with 19.1 years for women in the lowest wealth quintile. This pattern is also seen among ever-married women age 25-49 (Statistics Indonesia, 2012).

Less than 4 in 10 currently married women and less than 2 in 10 men think domestic violence against women is acceptable. This acceptability differs across demographics, with domestic violence acceptability decreasing by a woman’s increased age, education, and wealth quintile. In addition, urban women were less likely (29.8 percent) to accept any reason for domestic violence as compared to rural women (39.5 percent). Adolescent women age 15 to 19 reported the highest acceptability of domestic violence, at almost 45 percent. Similar trends were seen among men across background characteristics who reported that they find domestic violence less justifiable, compared to women. Like women, adolescent men age 15 to 19 had the highest acceptability of violence against women, at approximately 48 percent (Statistics Indonesia, 2012). Details on domestic violence acceptance by background characteristic and gender can be found in Appendix 3.


These indicators have implications for maternal and child health. For example, women who participated in at least three household decisions had greater percentages of receiving ANC from a skilled provider, delivering with a skilled provider, and receiving postnatal care in a timely manner. In addition, women who participated in more household decision-making reported lower infant, child, and under-five mortality than those who participated in zero household decisions. This also holds true among those women who are more accepting of justifications for domestic violence, with those who find it less justifiable receiving more health services than those who find it more justifiable (Statistics Indonesia, 2012).

Educational attainment has long been an indicator of an empowered population, with women who have higher educational levels facing greater economic security and better health outcomes than those of lower education attainment. In Indonesia, the majority of women attain at least a primary school education. Secondary school completion is almost 22 percent nationally, but varies by province, with a completion rate of only 17.5 percent in the province of Gorontalo, compared to over 45 percent on Riau Islands (Statistics Indonesia, 2012).

Overall educational attainment is similar between genders, with most men (27.7 percent) achieving at least a primary school education and approximately 27 percent achieving a high school education. School participation rate drops off considerably by age 16 for adolescent girls and women, with less than three quarters (71.9 percent) of 16 to 18-year-old adolescent women enrolled in school compared to over 95 percent of 13 to 15-year olds. This sharp drop in school participation is similarly seen in young men at this age as well. With at least an elementary school education, most Indonesians are literate, at over 95 percent of the total population. As of 2015, approximately 93 percent of women and 97 percent of men were literate (Statistics Indonesia, 2012).

3.3. Maternal Health and Nutrition Maternal and child health (MCH) has improved significantly in the past few decades in Indonesia. Maternal mortality has decreased, from 390 to 359 per 100,000 live births between 1991 and 2012. However, undernutrition is common among women of reproductive age, with 25 percent of adult women stunted, including 20 percent of non-pregnant and 25 percent of pregnant women (Statistics Indonesia, 2012). Undernourished mothers have a greater chance of giving birth to low-weight babies than mothers who are adequately nourished. This poses great danger to neonates, with 60 to 80 percent of neonatal deaths occurring among those who are low birthweight (UNICEF, 213). MCH indicators by province are discussed further in the following sections. According to the 2017 Global Nutrition Report, Indonesia is on course to meet World Health Assembly nutrition targets for exclusive breastfeeding and is off course for four MIYCN nutrition indicators, including under-five stunting, wasting, overweight, and women’s anemia.

3.3.1. Antenatal Care and Nutrition

ANC Prevalence and Coverage In Indonesia, maternal nutrition has been shown to be a determinant of multiple fetal outcomes, including growth, birthweight, and infant mortality (Madanijah et al., 2016). Proper antenatal care

Table 3. Percentage of female highest educational attainment aged 15 years and older, Indonesia 2012

Education Level Percentage (%)

No education 3.3% Some primary 10.7% Completed primary 22.5% Some secondary 28% Completed secondary 23.4%

More than secondary 12.2%

Source: IDHS 2012


(ANC) provides critical opportunities for health and nutritional counseling for families. The 2017 IDHS data reported that 93.9 percent of pregnant women received ANC serviced by a health worker, with 77.4 percent of pregnant women attending at least four ANC visits. Indonesia’s Ministry of Health (MoH) recommends that pregnant women receive four ANC visits encompassing the following interventions (Statistics Indonesia, 2012; UNICEF Indonesia 2012; Dixit et al. 2017):

• Height and weight measurements • Blood pressure measurement • Upper arm circumference measurement (MUAC) • Measurement of the peak height of the uterus (fundus uteri) • Iron folate supplementation • Tetanus toxoid immunization • Determination of fetal presentation and fetal heart rate (FHR) • Implementation of communication session (interpersonal communication and counseling,

including family planning) • Simple laboratory testing services (at least blood hemoglobin test (Hb), examination of urine

protein and blood type) • Case management

These ANC visits are recommended once in the first trimester, once in the second trimester, and twice in the third trimester. While most women in Indonesia seek ANC, about one in five wait until their second trimester (Statistics Indonesia, 2012). Almost all provinces met the 2015 Strategic Plan goal of 72 percent for fourth ANC visit coverage, except for the provinces of Central Sulawesi, East Nusa Tenggara (ENT), Maluku, West Papua, and Papua (Appendix 6) (Statistics Indonesia, 2012). These provinces also underperformed in other key maternal health indicators, as listed below in Figure 3. Ability to attend all ANC appointments varies widely by province, with wealth disparities

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First ANC visit Fourth ANC visit

Antenatal iron supplementation Health personnel-assisted deliveries

Healthcare facility-assited deliveries Postpartum visits

First natal visit

Figure 3. Provincial coverage of key maternal indicators as compared to national average, Indonesia 2015

Source: Indonesia Health Profile, 2015


being greater than urban-rural disparities (UNICEF Indonesia, 2012). For example, 99 percent of women in East Java received ANC from a skilled provider, compared to only 58 percent of women in Papua (Thomas & Yusran, 2013). Over 92 percent of women in urban areas received ANC coverage at least four times, compared to approximately 83 percent of rural women. However, women from the highest wealth quintile are almost one and a half times more likely to receive at least four ANC visits. ANC coverage is not impacted by a mother’s age, with women less than 20 years old receiving at least four ANC visits at the same prevalence as women age 35-49 (84.4 percent), with women of peak childbearing years (20-34) receiving full ANC visits at a slightly higher coverage (88.9 percent) (UNICEF, 2016).

ANC Determinants Data from the 2014 GAIN Landscape Assessment found that women in East Java mostly seek ANC from midwives (88.1 percent and higher in rural areas), with the most common places to seek ANC being private practices (63 percent), Puskesmas (9 percent), and Posyandus (5 percent. The latter two are more common in rural areas. Neonatal mortality amongst Indonesian children whose mothers attended ANC visits and had births attended by a skilled healthcare provider was one-fifth of those whose mothers did not receive these services (UNICEF Indonesia, 2012). An analysis of seven regions in Indonesia indicates that Sulawesi, Maluku, Papua, and West Papua are at a disadvantage when it comes to accessing ANC (Tripathi & Singh, 2017).

Beyond promoting proper health and nutrition, evidence shows that attending ANC appointments promotes the utilization of subsequent health services, including delivery in healthcare facilities (Dixit et al., 2017). Delays or absence of accessing ANC can stem from cultural beliefs, including taboos around pregnancy. One study in the Ende district of ENT indicated that mothers with higher education had more ANC visits on average than those with lower education (Pardosi et al., 2015). Women in West Nusa Tenggara (WNT), East Java, and Papua report beliefs that they should keep their pregnancies secret until their belly is showing. This creates missed opportunities for early ANC. Social shame contributes to stigma of pregnancy outside of marriage. These women are less likely to attend ANC or facility-based delivery, putting them at an increased risk of maternal or neonatal mortality (Thomas & Yusran, 2013).

Efforts have been made to reduce these disparities in ANC appointment attendance and facility-based birth through the Integrated Health Service Post, Posyandu, which utilizes volunteer-staffed village health workers, or kaders (or cadres), to be trained in basic health care issues such as nutrition, MCH, family planning, immunization, and diarrhea prevention. Particularly important for pregnant women, kaders and midwives distribute fortified sandwich biscuits to pregnant women with chronic energy deficiency in certain areas. The distribution of these biscuits serves as an important opportunity to counsel pregnant women on health and nutrition and as to why the biscuits are important for the promotion of both (Andriani et al., 2016). While kaders are essential to the documentation of pregnant women in each catchment area and provide encouragement for women to attend ANC appointments, evidence has indicated they cannot effectively fulfill their roles due to their lack of professional training, their volunteer status, and uneven distribution, particularly among high needs areas that are rural or geographically isolated (Indonesian Academy of Sciences, 2013; Thomas & Yusran, 2013).

Antenatal Nutrition and Micronutrient Coverage Mid-upper arm circumference (MUAC) is used to determine an expectant mother’s body mass, as opposed to the age-specific body mass index (BMI) used for non-pregnant individuals. A MUAC of less than 23.5 cm is considered a sign of undernutrition and poses risk for the mother and fetus. As of 2013, 24.2 percent of pregnant women in Indonesia are below this threshold. The mean MUAC for


pregnant women under 17 is, on average, below 23.5 cm. Mean MUAC increases with age, with those who are pregnant at 15 reporting an average MUAC that is 1.6 cm less than those who are 25 (Table 4). Among pregnant women 25 years or older, the prevalence of thinness increases and is significantly higher than among their non-pregnant peers (GAIN, 2014).

In general, the intake of several nutrients by pregnant women in Indonesia is below the estimated average requirements (EAR), including macronutrients such as carbohydrates, fats, and proteins, as well as micronutrients such as iron and Vitamin A (Hartriyanti et al., 2012; Madanijah et al., 2016). Evidence of maternal malnutrition from both a national review and in Bogor District, Java suggests prenatal deficiencies in micro- and macro-nutrients for expectant mothers, particularly iron and calcium (UNICEF Indonesia, 2012; Tripathi & Singh, 2017). It is unknown whether calcium has been systematically introduced to the routine antenatal supplementation among government healthcare facilities. Evidence from Madura, East Java indicates that during pregnancy, caloric intake drops to 75 percent of the recommended 1900 kcal and 44g of protein a day. Authors from this study concluded that traditional beliefs on prenatal nutrition as well as food insecurity contributes to this decrease.

The World Health Organization (WHO, 2016a) recommends daily oral iron and folic acid supplementation with 30 mg to 60 mg of elemental iron and 400 µg (0.4 mg) of folic acid for pregnant women to prevent maternal anemia, puerperal sepsis, low birthweight, and preterm birth. The Indonesian MoH

recommends that pregnant women take at least 90 iron-folate tablets throughout the duration of her pregnancy. These tablets are paid by the government and distributed through Puskesmas and private-practice midwives. These tablets are packed in blister packs with 30 tablets that contain 60 mg ferrous fumarate and 400 mcg folic acid. The generic, government-issued tablets typically confer more side effects than more expensive ones, which have a better coating, use other iron compounds with less side effects, and are packed to ensure a better shelf life.

According to the 2012 Indonesia Demographic Health Survey (IDHS), 76 percent of women who received ANC took iron-folate syrup or tablets. In 2015, 33 percent of Indonesian women were supplemented with 90 iron folate tablets during their pregnancies, with Central Sulawesi (63 percent), West Papua (47 percent), Maluku (47 percent), and Papua (24 percent) having the lowest coverage, compared to approximately 97 percent of women in Jakarta. A full list of iron-folate supplementation by province is reported in Appendix 6. However, these numbers represent distribution only, and no national data exists regarding compliance. The 2012 IDHS had women self-report the number of days they took iron folate tablets or syrup during the pregnancy of their last birth. Results showed 30.9 percent took iron folate for less than 60 days, 7.1 percent took it between 60 and 89 days, and 32.7 percent took iron folate supplements the recommended 90 days of their pregnancy (Statistics Indonesia 2012). Almost 23 percent of those women surveyed reported that they did not take any iron folate supplements during their last pregnancy (Figure 4).

While anemia continues to be a problem for pregnant women in Indonesia, it may be an indicator closest to meeting international targets. UNICEF considers Indonesia one of the countries closest to moving from ‘off course’ to ‘on course’ for anemia reduction among women aged 15-49 years. Data

Table 4. Mean MUAC (cm) of pregnant women age 15-25, Indonesia 2013

Age Mean MUAC ± SD (cm)

15 23.8 ± 2.7

16 23.6 ± 2.7

17 24.0 ± 2.5

18 24.1 ± 3.0

19 24.2 ± 2.3

20 24.5 ± 3.3

21 24.3 ± 3.2

22 25.4 ± 3.3

23 24.8 ± 2.8

24 25.4 ± 3.3

25 25.4 ± 3.3

Undernutrition cut-off

23.5

Source: GAIN, 2014


from the 2013 RISKESDAS found that 37.1 percent of pregnant women are anemic, compared to 22.7 percent of non-pregnant women aged 15-49 years. These disparities were not found to be marked between urban (36.4 percent) and rural (37.8 percent) populations (Statistics Indonesia 2012).

In 1999, the World Health Organization (WHO) and the United Nations University (UNU) jointly proposed a multiple micronutrient (MMN) supplement for pregnant women to be used in developing countries. This was evaluated in a study conducted in West Java. The cluster-randomized controlled trial evaluated the effect of the MMN supplementation in comparison with iron–folic acid on birth size, pregnancy outcome, and micronutrient status in women. The study concluded that these MMN capsules were as effective as iron-folate supplements at improving anemia in

pregnancy, even though they contained half of the iron-folic acid supplement. In addition, those in the MMN group had a 3.3 percent combined rate of miscarriage, stillbirth, or neonatal death as compared with 6.9 percent for those taking iron-folate supplements only (p < .049) (Sunawang et al., 2009). There is also evidence that MMN supplementation during pregnancy can improve the unborn child’s health for years to come. One randomized trial in Lombak, which investigated the benefit of MMN supplementation, found that when pregnant women are undernourished or anemic, provision

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AcehNorth SumateraWest Sumatera

RiauJambi

South SumateraBengkuluLampung

Bangka Belitung IslandsRiau IslandsDKI JakartaWest Java

Central JavaDI Yogyakarta

East JavaBanten

BaliWest Nusa TenggaraEast Nusa Tenggara

West KalimantanCentral Kalimantan

South KalimantanEast KalimantanNorth Sulawesi

Central SulawesiSouth Sulawesi

Southeast SulawesiGorontalo

West SulawesiMaluku

North MalukuWest Papua

PapuaIndonesia

None <60 60-89 90+

Figure 4. Number of days women took iron folate tablet or syrup during pregnancy of last birth, Indonesia 2012

Source: IDHS, 2012


of MMN supplements can improve the motor and cognitive abilities of their children up to 3.5 years later, particularly for both motor function and visual attention/spatial ability (Prado et al., 2012). In the same study, maternal MMN supplementation, but not iron/folic acid supplementation, protected children from the detrimental effects of maternal undernutrition on child motor and cognitive development. Vitamin A deficiency was found among approximately 10 percent of pregnant women in a study in West Java in 2014. It is expected that these prevalences are higher in women of lower wealth quintiles, who spend a larger proportion of their money on rice than vegetables and animal products (Statistics Indonesia 2012).

Antenatal Nutrition Social Norms and Practices According to the 2014 GAIN Landscape Assessment, there is widespread confusion among both the community and providers regarding the concept of anemia, or “kurang darah”, which translates to “not enough blood”, and low blood pressure, known as “low blood”. The government issued iron-folate tablets are called Tablet Tambah Darah, or “Tablets to Increase Blood”, leading some people to associate these tablets as “increasing blood” and are mistakenly associated with hypertension. This is support by evidence from formative research conducted in 10 provinces, where poor compliance was related to the perception that the Tablet Tambah Darah is only needed to treat low blood pressure. In addition, side effects including nausea and the bad taste and smell associated with the tablets cause many women to avoid or discontinue use before the recommended 90 days of compliance. Understanding of the importance of preventing and treating anemia is low, as many throughout Indonesia believe it is normal to be anemic during pregnancy. Some mothers believe that taking these supplements will cause increased birthweight and a more difficult delivery. Limited counseling has been reported at health facilities in regard to these iron-folate supplements, and the MCH Book that every woman receives upon initiation of ANC at government health facilities simply mentions that “iron tablets are not dangerous for your baby” (GAIN, 2013).

In general, the Indonesian diet is high in carbohydrates and low in animal protein and fats, with the most common sources of protein being eggs and tofu/tempe. One Indonesian saying goes, “if you haven’t eaten rice, you haven’t eaten.” Caloric restrictions during pregnancy are common, although it is unknown whether this is due entirely to food taboos or food availability (GAIN, 2013). Practices vary across Indonesia. The following are some of the prominent antenatal feeding practices and taboos in Indonesia:

• A study in Central Java found that 26 percent of pregnant women avoid some foods that are nutritionally beneficial due to food taboos (Statistics Indonesia, 2012).

• Evidence from Bogor suggests that women do not change their nutritional habits once they become pregnant, with rice continuing to make up a large proportion of the diet (Madanijah et al., 2016).

• In Papua and Nusa Tenggara Timur (NTT), women are advised not to eat eggs, rice, tofu, and lentils 9Thomas & Yusran 2013).

• In Bali, women prioritize the uptake of vegetables over protein, as it is thought that vegetables increase the production and “freshen” the taste of breastmilk, while meat acts to turn breastmilk sour, making the baby not want it (Wulandari & Klinken Whelan, 2011).

• A quantitative survey of women in West Java showed that 37 percent of respondents assume some sort of fruit and vegetable restrictions during pregnancy, including restricting the intake of pineapple, avocado, pomegranate, guava, orange squash, durian, jack fruit, papaya, sugar cane, and eggplant (Trtisyani, 2012).


• In East Java, food taboos for pregnant women include many of the same as the rest of the island, such as goat meat, pineapple, durian, glutinous rice (ketan), spicy foods, coffee, or peanuts.

• A qualitative study in Banten reported that approximately a quarter of women interviewed reported limiting food intake during pregnancy, with the belief that less food consumed would produce a smaller baby and would make giving birth easier. These women reported a common Indonesian belief that foods were either ‘hot’ or ‘cool’, with ‘hot’ foods being avoided, especially in the first trimester. Some examples of ‘hot’ foods include pineapple, calamari, soft drinks, and ice. It is believed that ‘hot’ food negatively affects the mother or baby. Chili is believed to make childbirth more painful by making the tissue rougher, and calamari is believed to be dangerous to the baby (Setyowati, 2010).

Despite these differences from one locale to another, rice is generally considered a staple and is particularly encouraged as it is thought to provide strength during pregnancy and delivery. Postnatal nutrition practices are documented later in the report. A summary of pre- and post-natal food restrictions is documented below in Table 5.

Table 5. Foods restrictions during and after pregnancy for women based on cultural beliefs, by province

Province Foods Restricted

Bali Meat in general

Banten ‘Hot foods’: Chili, pineapple, calamari, eggplant, soft drinks, ice

Central Java Chicken, beef, eggs, fish, and tempe. bananas, tape (fermented cassava), salt, peanuts, fried foods

East Java Goat meat, pineapple, durian, glutinous rice (ketan), spicy foods, coffee, peanuts, pindang (a type of fish), eggs, chicken, beef, fish, tempe. bananas, tape (fermented cassava), salt

NTT Eggs, rice, tofu, lentils

Papua Eggs, rice, tofu, lentils

West Java ‘Hot foods’: Pineapple, avocado, pomegranate, guava, orange squash, durian, jack fruit, papaya, sugar cane, eggplant

Sources: Wulandari & Klinken Whelan, 2011; Trtisyani, 2012; Setyowati, 2010; Probandari et al., 2017a; Probandari et al., 2017b

Jamu, a traditional herbal medicine, is used for many purposes in Indonesia and is popular during pregnancy. Different types of jamu preparations are recommended before, during, and after pregnancy to improve the strength of reproductive organs and ensure a healthy mother and child. These preparations usually include various roots, leaves, bark, and other parts of indigenous plants that are then boiled together, strained, and made into a powder that is ingested as a tea (Mangestuti et al., 2007). Other preparations are for bathing or applying topically to the body. For example, Myrsinaceae, a flowering plant, has been used for many generations to induce and facilitate childbirth, as well as postpartum medicine (Rahman et al., 2009). In Bali, many women rely on jamu in lieu of ANC supplements, as these practices have been passed down through many generations. Many adhere to herbal remedies out of superstition, believing that unless the remedies are followed, the health of their baby would be at risk (Wulandari & Klinken Whelan, 2011). Some of the herbal treatments prescribed include tamarind, turmeric, cinnamon, clove, and coconut. Many women reported that they don’t talk to their midwives about taking these supplements, as they believed that healthcare professionals did not understand these practices and would forbid them. Women reported that they preferred herbal remedies over supplements or medicines because they believed they were safer and had no side effects (Andriani et al., 2016; Rahman et al., 2009).


ANC Influencers Many pregnant women are influenced by their immediate family’s ANC practices and the traditions that have been passed down through generations. Nutritional restrictions are often perpetuated by influencers in the mother’s life, such as elders and mothers-in-law. In Bali, pregnant women reportedly take this advice without question because they trust their family members, and they want their families to be happy with them (Trisyani, 2012). One study that examined the knowledge, attitudes, and practices of nutrition during pregnancy in Banten concluded that husbands, mothers-in-law, village midwives, kaders, and village leaders all have more power in determining a woman’s nutrition than the woman herself. Over one half of the women interviewed believed they had to avoid some kinds of foods during pregnancy, stressing that these practices had been recommended by their parents. It is often difficult for women to disobey these influencers because, although women usually buy and prepare the food, they often have to get permission from their husbands or mothers/mothers-in-law regarding what they are going to buy. This forced some women to eat more nutritious food in secret in an attempt to subvert cultural norms and pressure from these influencers. In addition, in some households women typically eat last, including during pregnancy, due to conservative beliefs that regard the husband as the breadwinner and the family member deserving the best food (Setyowati, 2010).

3.3.2. Birth Practices The Indonesian MoH has made safe delivery—defined as delivery assisted by health personnel in healthcare facilities—a key maternal health indicator for its 2015-2019 strategic plan (Statistics Indonesia, 2012). The 2017 IDHS data reports that 79 percent of women deliver their babies in a health facility. The percentage of births assisted at delivery by health workers has increased from 83 percent in the 2012 IDHS to 90.9 percent in the 2017 IDHS. However, these percentages are lowest in Papua (62.5 percent), Maluku Utara (72.2 percent), Maluku (72.5 percent), Nusa Tenggara Timur (72.6 percent), and Papua Barat (74.8 percent). The majority of births in Indonesia are attended by one of the following:

• Traditional birth attendants (TBA); • Parajis, who reside within the communities they serve and are not formally educated; or • Midwives, who practice in primary care facilities and hospitals and have undergone formal

training (Agus et al., 2012).

Although there has been a shift away from the use of TBAs, they still play a role in assisting in deliveries in rural areas (20 percent), birthday to mothers with no education (34 percent), high-order births (30 percent) and for births to mothers in the lowest wealth quintile (32 percent) (IDHS 2012).

Obstetric complications include those incurred by the mother of the fetus during or immediately after pregnancy. Coverage of obstetric complication care in Indonesia has improved significantly, from 45 percent in 2008, to 79 percent in 2015. The provinces with the lowest coverage include Central Kalimantan (36 percent), North Sumatera (31 percent), West Papua (18 percent), and Papua (13 percent) (Statistics Indonesia, 2012).


Birth Registration With almost 20 percent of births not occurring in a health facility, this creates difficulties for birth registration. Without a birth registration, children often cannot access basic health and social services, including those related to nutrition. National data from SUSENAS 2015 reported that 73 percent of Indonesian children under five had birth certificates. According to this, Indonesia ranks in the bottom 20 countries in the world in its registration of children (UNICEF, 2010). The problem is worse in rural areas (65 percent) than in urban areas (80 percent) and among the poorest wealth quintile (62 percent) compared to the richest wealth quintile (88 percent). There are also differences between provinces with Nusa Tenggara Timur (34 percent) having the lowest rates for birth certificates and DI Yogyakarta (93 percent) having the highest rates. A study conducted in ENT, WNT, and West Java provided birth registration data for 1,978 children from the heads of households. Less than half (46 percent) of children from this study reportedly had a birth certificate (Duff et al., 2016). The following factors were associated with a child’s birth certificate ownership: marriage certificate ownership of the parents, higher household socioeconomic status, and older age of parents. Cost was another factor that prohibited parents from obtaining a birth certificate for their child, despite a 2013 legal amendment that eliminated fees for all civil registration and vital statistics (CRVS) documents. The implementation of these laws has been inconsistent across regions, and many parents report that they continue to pay hidden fees. In addition, acquiring the prerequisite documents, such as a parents’ marriage certificate, contributes to financial costs to obtaining a birth certificate (Duff et al., 2016).

Facility-Assisted Births The 2015 Strategic Plan set a target of 75 percent of assisted births taking place in healthcare facilities in Indonesia. As a nation, this target has been achieved, at almost 80 percent as reported in the 2017 IDHS. This varied by both province and rurality, with urban women having facility-based deliveries at a prevalence 113 percent higher than that of rural women (UNICEF Indonesia 2012). Table 6 shows the provinces that did not meet the 2015 Strategic Plan Target for facility-assisted births.

Regardless of geographic location, the poorest 40 percent of women have a higher tendency to deliver at home. Despite higher population density and easier access to health services, over 25 percent of the bottom two urban quintiles still deliver at home. For those living in rural areas, 78 percent of the poorest quintile deliver at home. These home births may or may not be accompanied by a skilled birth attendant such as a midwife. According to secondary analysis of 2012 IDHS data, when a mother does choose to deliver at a facility, they most frequently deliver at a private facility assisted by a midwife (Rajkotia et al., 2016). Another nationally representative study identified Sulawesi, Maluku, Papua and West Papua as being particularly disadvantaged in regards to safe delivery services (Tripathi & Singha, 2017).

Table 6. Provinces that failed to meet 2015 Strategic Plan Target for 75% coverage of facility-assisted births, Indonesia, 2015

Province Prevalence of

facility-assisted births (%)

Sumatera Utara 61.1% Riau 52.9% Jambi 56.4% Bengkulu 66% Banten 72.3% Nusa Tenggara Timur 65.8%

Kalimantan Barat 59.9%

Kalimantan Tengah 40.9%

Kalimantan Selatan 66.9%

Sulawesi Tengah 58.1%

Sulawesi Tenggara 48.3%

Sulawesi Barat 63% Maluku 28.5% Maluku Utara 34.1% Papua Barat 50.5% Papua 44% Source: IDHS, 2017


Barriers to Facility-Assisted Delivery

One study in the provinces of ENT and West Java interviewed TBAs, mothers, midwives and volunteers at Posyandus, and other stakeholders to understand the factors that deter mothers from delivering at health facilities. The study concluded the following barriers to facility-assisted delivery 9Nasir et al., 2016):

1. Preference for TBA care. This was attributed to the fact that TBAs are typically older than midwives, they are perceived to have more experience, and their knowledge is trusted. They also allow for delivery in the comfort of the home where families can adhere to cultural practices.

2. Traditional beliefs. The use of jamu, as well as traditional religious practices of the area are rooted in merapu, which posits that ancestors at the center of all practices, including birth. Therefore, attending health facilities for any pregnancy care can be seen as disrespectful to ancestors, and many believe that this may cause harm to current or future pregnancies.

3. Limited responsiveness of health providers to local traditions. For example, it is tradition for women to be bathed in warm water after delivery, but many Puskesmas do not have warm water at their facilities.

4. Distance to healthcare facilities. This includes poor road conditions. 5. Cost of travel. While ambulance services are provided free of charge, individuals report

difficulties in calling an ambulance or reports of no fuel. 6. Indirect costs associated with accompanying family members. Examples include food and

accommodations for family members visiting from out of town for the birth.

This corresponds to another study conducted in ENT, where mothers cited similar barriers, which lead to TBA-assisted births and giving birth from home (Pardosi et al., 2015).

Health Personnel-Assisted Births Coverage of deliveries assisted by trained health providers has increased over recent years, from 83 percent in 2012 to 90.9 percent in 2017. Similar to facility-assisted birth prevalence, births attended by health personnel varies significantly by province. In ENT, mothers interviewed as part of one study revealed a high level of awareness of the importance of giving birth at a Puskesmas, or community health centers, with the assistance of a health professional. In this area, midwives were the main birth assistants for most women, followed by doctors, nurses, and TBAs. Most chose Puskesmas as their place of birth. The women who chose TBAs as their birth attendant had a higher neonatal mortality rate than those who gave birth at a health facility (Pardosi et al., 2015).

Barriers to Health Personnel-Assisted Births For those who prefer TBAs, it is often due to the TBA’s close proximity to the woman’s home at the time of birth and their adherence to traditional practices during pregnancy and delivery (Nasir et al., 2016). Interviews with women in West Sumatera indicated that women who preferred a TBA for ANC during pregnancy, preferred to give birth in government hospitals if they had complications (Agus & Horiuchi, 2012). Culture and rurality play important roles in who women seek to deliver their children, with studies conducted in East Java and West Sumatera identifying traditional beliefs as the greatest contributing factor to preference for TBAs (Agus et al., 2012). In Bali, many mothers rely on midwives for their births and view them positively, despite the fact that they adhere to traditional beliefs about pregnancy (Wulandari & Klinken Whelan, 2011). Interviews with women in East Java revealed the importance of both TBAs and midwives in ANC, delivery, and postnatal care, with women in favor of both working together (Agus et al., 2012).


In West Java, women who preferred TBAs noted that they trusted them more than midwives because they live in their community, speak the same language, and share the same culture (Brooks et al., 2017). Interviews with women in the city of Bangdung in West Java, revealed numerous factors that contributed to mothers’ decision to choose TBAs over midwives (Indrayani & Sipayung, 2016). TBAs were regarded as elders with more experience, while midwives were viewed as young and less experienced. Similar to other experiences of mothers across Indonesia, most women who chose TBAs did so because the TBAs advised women on traditional rituals before, during, and after pregnancy.

Women interviewed in Bandung perceived that midwives did not know about these customs, as they rarely performed or participated in local traditions related to pregnancy and birth. Mothers also felt TBAs were more inclusive, as they typically stayed with the mother from the time contractions started and provided services up to one week after the baby was born. Participants also felt that TBAs were cheaper than midwives, even though giving birth from government hospitals is free and encouraged under the JKN insurance. Besides the perceived cost, mothers reported logistical hassles involved with facility-births, where most midwives practice. While some mothers recognized that midwives were safer and are more knowledgeable in the science of birth, many mothers did not realize the extent of the danger presented by giving birth with TBAs, and therefore took on unknown risks to adhere to tradition (Indrayani & Sipayung, 2016).

However, the training of those labeled as skilled birth attendants in Indonesia, which can include midwives or nurses, varies widely, with many unable to perform necessary lifesaving interventions needed during obstetric complications (Indonesian Academy of Sciences, 2013). Indonesia’s MoH initially discouraged the use of TBAs. However, recent joint engagement of TBAs along with midwives is now gaining acceptance as a way to promote facility-based deliveries and the uptake of postnatal care in community health centers. This collaboration also promotes cross-professional training (Pardosi et al., 2016).

3.3.3. Postnatal Maternal and Newborn Care Practices

Postnatal Care Prevalence and Coverage Postpartum care is recommended by the Indonesian MoH three times—once in the first three days after delivery, once between day 4 and 28 post-delivery, and once between day 29 to 42 post-delivery (Statistics Indonesia, 2012). Care provided at these appointments includes:

• Vital sign examination • Abdominal examination • Exclusive breastfeeding counseling • Information, education, and communication on postpartum maternal health and neonatal

health, including family planning • Postpartum family planning services

Approximately 31 percent of women receive “timely” postnatal care, which is defined as care within six to 48 hours after birth. Postpartum coverage for all three visits has improved significantly, from 18 percent in 2008 to 87 percent in 2015, although this number has plateaued in recent years. This increase can, in part, be attributed to better support of Puskesmas and Posyandus by the MoH, including intensifying home visits for those who miss their appointments (Statistics Indonesia, 2012). Urban-rural inequities persist as it relates to timely maternal post-natal care, with approximately 86 percent of urban women receiving timely postnatal care, as compared to approximately 74 percent of rural women. This varied widely across provinces, with Riau (63 percent), Maluku (44 percent), West Papua (29 percent), and Papua (28 percent) having the lowest coverage of mothers who


receive timely postnatal care (Appendix 6). Twenty-six percent of all mothers in Indonesia receive no postnatal care (UNICEF Indonesia, 2012). Seventy percent of mothers in Papua receive no postnatal checkup in the first two days after birth, compared to just 4 percent in DI Yogyakarta (Statistics Indonesia, 2012).

The MoH recommends newborns attend their first neonatal visit between six and 48 hours after birth. This visit covers counseling for newborn care and exclusive breastfeeding, as well as the administration of a Vitamin K injection, and Hepatitis B injection, if not already received. On average, 84 percent of babies received their first neonatal visit (Statistics Indonesia, 2012; UNICEF Indonesia 2012). The Strategic Plan Target for 2015 set a goal of 75 percent for timely first neonatal visits in all provinces. Ten provinces failed to meet this goal in 2015 (Table 7) (Statistics Indonesia, 2012).

Most (35 percent) of neonatal visits were conducted by nurses, midwives, or village midwives, followed by pediatricians (6 percent), obstetricians (4 percent) and TBAs (2 percent) (Statistics Indonesia, 2012). As recommended by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), Indonesia’s MoH promotes postnatal care through home visitations by trained birth attendants, such as midwives, with various levels of uptake by province (Titaley et al., 2010).

Barriers to Postnatal Care New mothers often leave healthcare facilities soon after giving birth in order to return home to resume caring for older children. This is especially true in the conservative social culture of Aceh (Sutan & Berkat, 2014). Reports in East Java indicate that some mothers do not think they need postnatal services because they did not have any complications during their pregnancy (Agus et al., 2012). For those who do receive post-natal care, it is most often done by nurses, midwives, or village midwives. Fewer TBAs perform the first maternal post-natal check-up, ranging from zero to 12 percent across all provinces (Statistics Indonesia, 2012).

Traditional birth attendants often fill gaps where the MoH is unable to serve. They are known to conduct daily visits to bathe newborns, treat babies’ umbilical cords, and massage mothers’ stomachs to promote contraction of the uterus (Pardosi et al., 2015). This is supported by evidence from West Java, where mothers reported a preference for TBAs over midwives because they provide post-natal services up to one week after birth, such as bathing the mother and baby, washing clothing and bedding from the birth, ensuring clean detachment of the umbilical cord, and massaging the mother (Indrayani & Sipayung, 2016).

Research conducted in the Klaten district of Central Java found three categories of barriers to postnatal care utilization in villages (Probandari et al., 2017). These included:

• Mothers’ and family members’ health literacy regarding postnatal care; • Sociocultural beliefs and practices; and • Health service responses.

In this study, most mothers had limited knowledge of nutrition, lactation, and self-hygiene following birth. This gap in knowledge was filled by myths and misconceptions perpetuated by family

Table 7. Provinces that failed to meet 2015 Strategic Plan Target for the timing of the first neonatal visit, Indonesia, 2015

Province Prevalence of first neonatal visit (within first 48 hours of birth (%)

West Sulawesi 74% Gorontalo 71% South Sumatera 69% Central Sulawesi 52% North Maluku 51% Maluku 44% ENT 42% West Papua 20% Papua 15% South Sulawesi 11% Source: Indonesia Health Profile, 2015


members, including parents, parents-in-law, and other elder extended family members. Mothers who lived in the same households as these influencers were reportedly more likely to abide by these myths due to social pressures. In addition, mothers interviewed did not seek postnatal care outside of that which they received immediately following birth, unless there was a health complication (Probandari et al., 2017).

Postnatal Nutrition Coverage and Cultural Practices Around half (48 percent) of women in 2012 reported that they had received a vitamin A capsule in the two months after delivery of their last-born child—a slight increase from the 2007 IDHS figure of 45 percent. This ranged from 29.7 percent in Papua to 60.7 percent in East Java. Supplementation levels were lowest among women with no education and women in the lowest wealth quintile (23 percent and 38 percent, respectively) (Statistics Indonesia, 2012).

Cultural practices are also very specific related to postnatal care, especially in remote provinces. In NTT, it is customary to put new mothers and their babies into “smoking huts” for 40 days in an effort to cleanse their blood (Thomas & Yusran, 2013). In the Treggalek region of East Java, “tarak” is a traditional diet consumed by women up to 40 days after delivery, particularly in mountainous regions. This involves abstaining from proteins such as chicken, beef, eggs, fish, tempe, bananas, tape (fermented cassava), and salt. Staple foods are substituted in lieu of these foods and mainly consist of white rice and boiled vegetables. There is evidence that this is also practiced during pregnancy, especially during the third trimester (Pudjirahaju et al., 2017). These practices are typically encouraged under the direction of TBAs. Similar food restrictions were also seen in the Klaten district of Central Java, where mothers were advised to abstain from fried foods and peanuts in addition to the others mentioned in the “tarak” diet (Probandari et al., 2017). According to women interviewed in this region, these foods were perceived to delay healing related to episiotomies and cesarean surgery, and that eating animal products would negatively harm both mother and baby. Across Java it is popular to drink herbal “potions” to facilitate breastfeeding and promote health. In East Java, post-partum women are discouraged from eating spicy foods. In addition, eggs and pindang (a type of fish) are discouraged due to the belief that they cause itch (Probandari et al., 2017).

3.4. Neonatal and Child Health

Neonatal Health Prevalence and Coverage Neonatal, infant, and under-five mortality has decreased significantly since the 1990’s. Neonatal mortality rate (NMR), as defined by deaths incurred in the first 28 days of life, has decreased from 32 to 15 per 1,000 live births between 1991 and 2017 (Figure 5). Infant mortality rates have decreased from 68 to 24 per 1,000 live births between 1991 and 2017. Overall under-five mortality has decreased from 97 to 32 per 1,000 live births between 1991 and 2017. Half of all under-five deaths are that of newborns (UNICEF, 2016).


Source: IDHS, 2017

The preliminary 2017 IDHS does not report neonatal and post-neonatal mortality by province. However, the 2012 IDHS does have this data and has reported an NMR of 20 per 1,000 live births (Appendix 7), ranging from 13 in South Sulawesi to 37 in North Maluku. Post-neonatal mortality, as defined by death between 28 days and one year, was 14 per 1,000 live births in 2012, ranging from a rate of 7 in the provinces of Bangka Belitung, Jakarta, and DI Yogyakarta to a rate of 39 in West Papua. NMR in rural areas is 24 deaths per 1,000 live births and 15 deaths per 1,000 live births in urban areas for an urban-to-rural ratio of 0.6 (UNICEF, 2016). NMR among the households from the lowest wealth quintile is 28 neonatal deaths per 1,000 live births, compared to 9 deaths per 1,000 live births among the households from the highest wealth quintile. The NMR for younger mothers (35 per 1,000 live births) is nearly two times higher than for mothers aged 20-29 (18 per 1,000 live births). In addition, newborns with less educated mothers are more than three times more likely to die during the first month compared to those born to mothers with higher education (UNICEF, 2016).

In Indonesia, the main causes of neonatal deaths in 2015 were prematurity (35.5 percent), birth asphyxia and trauma (21.6 percent), and congenital abnormalities (17.1 percent) (UNICEF, 2016).

Low Birthweight A child’s birthweight or size at birth is an important indicator of the child’s vulnerability to illnesses and chances of survival. Children whose birthweight is less than 2.5 kilograms, i.e., low birthweight (LBW), have a higher risk of early childhood death. Of the neonates with a reported birthweight in 2013, 10.2 percent weighed less than 2.5 kilograms at birth in Indonesia. Children born to younger mothers, to mothers who did not complete primary school, and to mothers in the lowest wealth quintile were more likely to have weighed less than 2.5 kilograms at birth. The prevalence of LBW also has a negative association with mother’s education. Mothers who completed at least a primary school education gave birth to fewer LBW babies than those who had not completed primary school (Figure 6) (Statistics Indonesia, 2012).

32

15

68

24

97

32

0

20

40

60

80

100

120

1991 2017

Neonatal Mortality Rate Infant Mortality Rate Under-5 Mortality Raate

Figure 5. Neonatal, infant, and under-five mortality rates per 1,000 live births in Indonesia between 1991 and 2017


Source: IDHS, 2012

A recent analysis of the 2010 RISKESDAS indicated that numerous factors contributed significantly to stunting among children 12-23 months, including LBW, gender (boys), history of neonatal illness, and poverty. However, LBW was determined to be the most significant determinant, with infants who were born LBW being 1.74 times more likely to be stunted than those born with normal weight (Aryastami et al., 2017).

Approximately 89 percent of all births in Indonesia had a reported birthweight, ranging from 37 percent in Papua to over 99 percent in DI Yogyakarta and Bali. To capture those births that were not weighed, the IDHS asked for subjective approximations from mothers, asking whether their child was born, “very small”, “smaller than average”, or “average or larger”. These indicators, while subjective, provide important gaps in data for those mothers who gave birth at home. Approximately 13 percent of all newborns were described as “very small” or “smaller than average” by their mothers, ranging from 5.9 percent in Papua to 20.6 percent in South Sulawesi. Other provinces that reported their newborns in this way include the other provinces in Sulawesi (15.8 percent–19.6 percent), as well as the island of Maluku (14.1 percent–14.9 percent). The likelihood of a child being reported as very small or smaller than average at birth does not vary much by the child’s birth order, mother’s smoking status, or urban-rural residence. Children with mothers in the highest wealth quintile are less likely to be reported below average in birth size (Statistics Indonesia, 2012). Details about LBW and its relation to mother’s background information can be found in Appendix 8.

Barriers to Neonatal Health Neonatal deaths and complications can be prevented, but are constrained by access to healthcare, skills of the health personnel, socioeconomic status, a referral system that has not functioned well, late detection of risk factors, and poor awareness by parents of when to seek medical help. Neonatal complications care refers to treatment provided for ill neonates and/or neonates with congenital abnormalities or complications/emergencies. This care is performed according to standards administered by skilled health personnel (physicians, midwives or nurses) who are well trained to do their job either in a patient’s house, a basic healthcare facility or in a referral healthcare facility. The achievement of neonatal complications care decreased, from 59.7 percent in 2014 to 51.4 percent in 2015. In addition to declining performance, there were still large disparities between provinces. In 2015, the province of Bangka Belitung Islands achieved the highest coverage of neonatal complications care at 90 percent, followed by Central Java with 89.2 percent, and East Java with 82.9

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N O E D U C A T I O N

S O M E P R I M A R Y

C O M P L E T E D P R I M A R Y

S O M E S E C O N D A R Y

C O M P L E T E D S E C O N D A R Y

M O R E T H A N S E C O N D A R Y

Reported birth weight <2.5 kg Size of child reported as very small or smaller than average

Figure 6. Percentage of LBW babies born LBW or smaller than average by mother's education, Indonesia 2012


percent. The provinces with the lowest achievement were South Sulawesi (2.6 percent), Papua (5.2 percent) and Maluku (8.9 percent) (Statistics Indonesia, 2012).

3.5. Experiences and Challenges with Health Service Delivery (check place)

Overview of Indonesian Health System Indonesia has historically struggled with disparities in health service delivery, primarily due to socioeconomic disparities, with the richest, urban population being seven times more likely to access health services than the poorest (Indonesian Academy of Sciences, 2013). Due to a decentralized system, provincial and district revenue tends to be higher in wealthier areas. External factors—such as the high cost of medical care, uneven distribution of health providers, and uneven distribution of public insurance—often serve as barriers to rural and socially disadvantaged women accessing facility-based care (Agus et al., 2012; Pardosi et al. 2015). Indonesia’s government and its allocation of resources and responsibilities shifted from a highly centralized system to one of the most decentralized and complex systems of governance in the world, with responsibility for healthcare delivery placed on local governments (UNICEF East Asia, 2017). It is based on a primary health care system, which positions community health centers (Puskesmas) as the central point of care, followed by hospitals and other specialty care centers (Indonesian Academy of Sciences, 2013).

Indonesia has undergone numerous iterations and attempts at a National Health Insurance Program. In 2014, a new, more comprehensive system was launched, titled Jaminan Kesehatan Nasional (JKN), and intended to close the gaps in care with the hopes of universal coverage being achieved by 2019 (Mboi, 2015). JKN intends to provide Indonesians with high-quality healthcare by strengthening primary care as the gatekeepers to hospitals (Ekawati et al., 2017). However, some researchers have concluded that achieving universal coverage by 2019 may be too ambitious based on the magnitude of those who are currently uninsured and a shortage of healthcare personnel to meet this end. (Jong, 2015). As of April 2016, 164 million Indonesians were covered under JKN (Rajkotia et al., 2016). Jamkesmas, government-financed health insurance for the poor, was absorbed under JKN and covers comprehensive maternity benefits, including prenatal care, institutional delivery, and postnatal care (Chedekel, 2017).

Puskesmas serve as a comprehensive health service for promotion, prevention, treatment, and rehabilitation through direct services, as well as indirect services including technical assistance, multi-sector collaboration, and community health education. There are more than 9,700 Puskesmas across Indonesia, serving approximately 25,000 to 30,000 people each, requiring at least one physician on staff (Statistics Indonesia, 2012; Oxford Business Group, 2015). Puskesmas provide the following services: MCH, family planning, nutrition, environmental health, communicable disease eradication, emergency treatment, public health education and promotion, school and sport health programming, and public health nursing. Recognizing a growing need for in-patient and obstetric emergency services at the community level, especially in rural areas, the Indonesian MoH has worked to upgrade facilities to meet the needs of its most underserved population. Currently, inpatient services are provided in about one half of facilities, with budget allocations for more in the future (Statistics Indonesia, 2012; Oxford Business Group, 2015). However, the specific timeline for the future upgrades was not found in time for this review. In addition to upgrading these services, the MoH has implemented a policy, Pegawai Tidak Tetap, which encourages doctors and midwives to apply for positions in rural areas by offering contracts with above average compensation (Oxford Business Group, 2015). To improve the development of traditional health services, the MoH sought to increase the number of health centers that provide traditional medicine and health services to its population. As of 2015, 16 percent of its over 9,700 health centers were registered or licensed to provide traditional health services (Statistics Indonesia, 2012).


While the number of Puskesmas increased from 2011, the ratio of health centers per 30,000 people decreased during this same time, from 1.16 to 1.15, indicating that the growth of these facilities was outpaced by the growth of the population. However, the ratio of hospital beds per 1,000 people increased since 2011 from 0.71 to 1.21 in 2015. In addition, these ratios vary widely, with Table 8 illustrating the provinces having ratios of less than one (Statistics Indonesia, 2012).

Barriers to Care The widest disparities in health service delivery, and subsequently maternal and newborn health outcomes, occur in Eastern provinces, including Papua and West Papua, Nusa Tenggara, and Maluku. (Thomas & Yusran, 2013) Indonesia’s barriers to accessing maternal and newborn health services include poor availability of care, quality of care, gender, financial constraints, geography, and remoteness.

Poor availability of care Due to a decentralized system, there are large disparities in the availability and quality of care between districts. Under the new JKN system, participants in one study from 2017 acknowledge that primary care centers are conveniently located, but access is often complicated by long wait times and short hours of operation (Ekawati et al., 2017). Mothers interviewed in ENT, suggested that midwives did not always provide sufficient attention during ANC appointments or enough time for the mother to discuss her problems with the midwife (Pardosi et al., 2015). Reports of staff absenteeism, lack of operational funds, and accountability deficits, are all factors that hinder community health centers across Indonesia (Thomas & Yusran, 2013). One study in Central Java indicated that in addition to performing postnatal care at the village level, midwives are responsible for running other mother and child health programs for large villages, some of whom do not reside there, adding to structural barriers such as cultural differences and long travel times (Probandari et al., 2017).

Currently, there are approximately 44 midwives per 100,000 people in Indonesia, significantly short of the 2019 target of 120 per 100,000. In fact, just two provinces, Bengkulu and Aceh, have met or exceeded the target at 133 and 124 midwives per 100,000 people, respectively. In West Java, there are just 21 midwives to serve 100,000 people. Eighty-eight percent of health centers in West Papua and Jakarta report having an inadequate number of midwives, compared to just six percent in Bali. Other provinces reporting a high percentage of midwife-deficient health centers include Papua (87 percent), Maluku (77 percent), North Sulawesi (77 percent), Southeast Sulawesi (76 percent), Central Sulawesi (71 percent), and ENT (70 percent) (Statistics Indonesia, 2012).

Poor quality of care Perception of care quality has been one barrier to patient-driven pre- and post-natal care. Midwives reported that while Puskesmas were often stocked with adequate equipment to perform their job, the equipment often lacked in quality and quantity. Interviews with mothers in Central Java revealed that maternity patients and their family members perceived the quality of health services offered at the village-level clinics to be low. Mothers in this area reported a preference for hospitals or private

Table 8. Ratio of health centers and hospitals per population, 2015

Province

Ratio of health centers

per 30,000 population

Ratio of hospital beds per

1,000 population

Bali 0.87 1.65 Banten 0.58 0.92 Central Java

0.78 1.17

DI Yogyakarta

0.99 2.94

East Java 0.74 1.07 ENT 2.17 0.88 Lampung 1.08 0.86 West Java 0.67 0.84 WNT 0.98 0.73 West Sulawesi

2.20 0.78



midwives as opposed to the free postnatal care that is offered at Puskesmas (Probandari et al., 2017).

Some reports indicated that Puskesmas also lack a patient-centered approach (Probandari et al., 2017). Interviews with women in ENT reported poor treatment by midwives during delivery, citing they lacked patience and a kind rapport (Pardosi et al., 2015). Some rural women, while recognizing the clinical skill of midwives, did not trust them, as they often came from different educational and socioeconomic backgrounds than those in villages, and therefore were perceived to not share the same cultural beliefs (Agus et al., 2012; Brooks et al., 2017).

Mothers interviewed in ENT also suggested that midwives did not always provide sufficient information during ANC appointments (Pardosi et al., 2015). This concern was supported by another survey in which mothers reported variations in the type and amount of information they received from midwives during postnatal visits, with many performing only perfunctory physical examinations that responded to relevant health complaints, and few mothers receiving information, education, and counseling on postnatal care practices (Probandari et al., 2017).

These barriers have led to dissatisfaction among some pregnant women with the services they’ve received. Seventy-five percent of women interviewed in a study in Banten reported dissatisfaction with the current maternal services provided to pregnant women. This was driven by reports and observations of poor communication with healthcare providers during pregnancy, particularly by midwives. Three sub-themes were identified as examples of this lack of communication, and were characterized by 1) midwives not being forthcoming with information and information being driven by questions from the woman; 2) concerns that midwives were not giving enough information; and 3) mixed comfort in talking to midwives and cadres. All participants felt that healthcare and nutritionfor pregnant women needed to be improved, and suggested there was a need for improvedcommunication and knowledge of nutrition among health workers, especially in rural areas(Setyowati, 2010). These barriers were verified, in part, by one study conducted among Indonesiannurses and midwives (Widyawati et al., 2015). The midwives reported their unease in providinghealth information to pregnant women. They also reported that they valued good communicationskills, but expressed that sometimes their patience waned with pregnant women who did notunderstand or would not listen to their advice. Ultimately these attitudes may prevent some womenfrom communicating important health information to midwives (WHO, 2016; Probandari et al.,2017).

Gender Gender norms and traditional views on women’s social positions influence disparities in care. In Ende District of ENT, many mothers in both urban and rural areas have difficulty making healthcare seeking decisions due to dependency on their husbands (Pardosi et al., 2015). They reported that they often defer to their husbands for healthcare decision-making for themselves and their children. Some women in ENT reported that their husbands supported what they wanted for their health during pregnancy, with opportunities to discuss what is right. Others mentioned positive support husbands gave, such as encouraging them to work less, promoting good nutrition and rest, and accompanying them to ANC appointments. However, some husbands preferred traditional medicine and TBAs over health facilities. Most mothers do not have the power to decide in these settings, with patriarchs of the family having the final word. This sometimes led to complications or neonatal deaths due to delays in care seeking in this study (Pardosi et al., 2015).

Traditional beliefs about who can make healthcare decisions varies by province. For example, in Papua, both the husband’s and wife’s families are required to be involved in deciding whether to seek services outside of the village in which they reside (Thomas & Yusran, 2013). According to the


2012 IDHS, a quarter of all surveyed women in West Papua and Papua reported that getting permission to go for treatment was a barrier in accessing health care (Statistics Indonesia, 2012). It was not reported whom they needed to get permission from. Interviews with midwives revealed that husbands are often the decision-makers surrounding his wife’s pregnancy, influencing where she should receive ANC (health professional or traditional healer) and where she should give birth (in a healthcare facility or at home).

Financial constraints While 85 percent of women have pregnancy care coverage, out-of-pocket health spending and high total household expenditure on health can push families into, or further into, poverty (WHO, 2016). Fifty-eight percent of women in Papua reported that getting money for treatment was a problem in assessing care. This was also true for 40 percent of women in West Papua, 38 percent in West Sulawesi, and 23 percent of women in Maluku (Statistics Indonesia, 2012). Having access to the free MCH services provided by JKN to the poor is vital for improvement of key MCH indicators, such as facility-based birth. One study showed that women of low socioeconomic status who have government-financed health insurance were 19 percent more likely to deliver in a health facility and 17 percent more likely to deliver with a skilled birth attendant compared to poor women without insurance (Chedekel, 2017).

Remoteness and geography Districts in Papua and Western Papua lack road and water infrastructure, which greatly affects the ability to access and deliver services. Fifty-percent of women aged 15-49 in Papua and 40 percent of same-aged women in West Papua reported distance to health facilities as a barrier in accessing care (Statistics Indonesia, 2012). This compares to only 5 percent of women reporting this as a problem in Jakarta. Some women in East Java reported having to walk up to two hours to reach the nearest health center, with road conditions worsening in the rainy season (Pardosi et al., 2015).

Overcoming barriers to care Understanding the important connection between service quality, its perception among pregnant women, and its subsequent uptake has sparked researchers to bridge this gap to improve the health of pregnant women. To improve maternal iron levels, a nonrandomized, controlled intervention in Central Java utilized midwives to deliver counseling and health education that promoted a healthy lifestyle during pregnancy, social support from their spouse or other family members, and adequate midwifery treatment, known as the “Four Pillars” approach (Widyawati et al., 2015). The intervention also sought to improve midwives’ professional attitudes while treating patients. As a result of the intervention, approximately 81 percent of women who participated in the intervention arm saw an increase in hemoglobin, compared to approximately 17 percent in the control arm (Widyawati et al., 2015). The results of this study highlight the importance of an integrated and personalized approach to prenatal care, and they emphasize the role of social support from a woman’s influencers in the health of her pregnancy.

3.6. Breastfeeding

Breastfeeding Overview Proper feeding practices are important for the survival, growth, development, and health of infants and young children. UNICEF and the WHO recommend that children be exclusively breastfed from birth to the first six months. Solid and semi-solid food should only be given starting at 6 months of age, and breastfeeding should continue well into the second year and beyond. In 2012, 194 countries of the World Health Assembly, a decision-making body of the WHO that focuses on specific


health agendas, gathered and committed to increasing the global rate of exclusive breastfeeding from 37 percent to at least 50 percent by 2025 (WHO, 2014b).

In 2015, Alive & Thrive quantified the economic toll that suboptimal breastfeeding takes on individuals and communities in seven Southeast Asia countries, including Indonesia. When children are not exclusively breastfed for six months, they are more susceptible to diarrhea and pneumonia, the two leading causes of child deaths worldwide. Breastfeeding also helps protect maternal health by reducing maternal deaths due to breast and ovarian cancer. Other benefits include savings in healthcare costs, reduction in cognitive losses that result in poor earning potentials, indirect cost of attending to infant illness (loss of work and transportation costs), and the cost of formula which is significant and reduces family income (Table 9) (Alive & Thrive, 2016).

Key findings in Indonesia

Optimal breastfeeding practices can:

• Save 5,377 children’s lives annually—an important contribution to reducing overall under-five childmortality

• Save $256,420,000 USD in health system expenditures annually

• Prevent $1,343,700,000 USD in annual wage losses by improving the learning abilities of children

• Reduce families’ out of pocket expenditures to treat diarrhea and pneumonia

• Save families up to 13.7% of their monthly earnings by not having to purchase formula

Source: The Cost of Not Breastfeeding. UNICEF and Alive & Thrive, 2015

Breastfeeding is a common practice in Indonesia, with 96 percent of children under two having ever been breastfed. According to the 2012 IDHS, only 42 percent of children under six months were exclusively breastfeed, well below the 2025 global target of 50 percent. The 2017 IDHS, however, indicates improvement, with 51.5 percent of all infants under six months in Indonesia being exclusively breastfed. Exclusive breastfeeding rates vary by province from a low of 26 percent in North Sulawesi to a high of 76 percent in Bengkulu (Appendix 11). Of the 34 provinces, all but six report exclusive breastfeeding prevalence above the 2025 goal of 50 percent. Those provinces below the goal besides North Sulawesi are North Sumatera (33 percent), West Java (35 percent), Central Kalimantan (38 percent), Maluku 40 percent), and Gorontalo (47 percent) (Statistics Indonesia, 2012).

Early Initiation of Breastfeeding Early initiation of breastfeeding refers to the provision of breastmilk to infants within one hour of birth. This practice is recommended for many reasons. Yellowish colostrum, rich in antibodies and protein, is produced on the first to the third day after birth. The main benefit of colostrum is the immune protection it confers to babies while they are unable to produce their own antibodies. Without these antibodies, babies are left vulnerable to infection and disease.

The following are other benefits of early breastfeeding:

• Early suckling stimulates breastmilk production and the release of oxytocin, which helpscontract the uterus and helps stop postpartum bleeding;

• It helps create a bond between mother and child;

Table 9. Key findings on high returns in investing in policies and programs to promote breastfeeding in Indonesia


• Over the long term it helps a mother to space her pregnancies due to amenorrhea (Black etal., 2013);

• Current evidence indicates that skin-to-skin contact between the mother and infant shortlyafter birth helps to initiate early breastfeeding and increases the likelihood of exclusivebreastfeeding for one to four months of life, as well as the overall duration of breastfeeding;and

• Infants placed in early skin-to-skin contact with their mothers also appear to interact morewith their mothers and cry less (WHO, 2017b).

According to the 2012 IDHS, about half (49 percent) of all children were breastfed within one hour of birth, and nearly two-thirds (66 percent) were breastfed within one day of birth. The percentage of children breastfed within one hour and within one day declined with mother’s education, although that is not uniform. Mothers assisted by a health professional during delivery were somewhat less likely to initiate breastfeeding within one hour or within one day than mothers whose delivery was assisted by a traditional birth attendant (TBA) or by relatives. Breastfeeding initiation within one hour of birth varies by province (Appendix 10) with a low of 26 percent in Riau to a high of 74 percent in West Nusa Tenggara. Newborns breastfed within the first day ranges from a low of 39 percent in West Sumatera to a high of 85 percent in West Nusa Tenggara (Statistics Indonesia, 2012). By 48 hours after birth, almost all mothers in Indonesia are breastfeeding.

Prelacteal feeding is when any food other than the mother’s milk is given before initiating breastfeeding. Prelacteal feeding within the first three days of life interferes with the immunological benefits of receiving colostrum and increases the risk of infection. The 2012 IDHS indicates that 60 percent of children born within the two years prior to the survey received a prelacteal feed during the first three days of life. Prelacteal feeding was most common among urban children, children delivered by a health professional, children of mothers with more education, and children in the highest wealth quintile (Statistics Indonesia, 2012). There is also a practice known as “tahnik” in Indonesia where a softened date is given to a newborn only once. Other prelacteal feeds include honey, banana, biscuit, and BMS given to newborn babies in both urban and rural areas (Dewi et al, 2016).

Of the studies found on the topic of early initiation of breastfeeding and/or prelacteal feeding, a 2012 UNICEF report summarizing findings for Aceh Province and Nias Island (based on the 2007 IDHS) states that only 39% percent of last-born children ever breastfed began breastfeeding within the recommended one hour after birth (UNICEF 2012). The 2012 IDHS indicates an improvement in that 46% percent of infants who were breastfed within one hour in Aceh Province. Nias Island was not listed separately (Appendix 10) (Statistics Indonesia, 2012). Another study which investigated infant feeding practices on Nias Island, North Sumatra Province, reported that 6 percent of mothers there never breastfed, 52 percent of mothers initiated breastfeeding within 6 hours of birth, and that 17 percent discarded colostrum. The reasons for not feeding colostrum to newborns included traditional beliefs that colostrum was considered “dirty,” “cheesy,” “indigestible” and of no nutritional value. Therefore, some mothers did not feel that colostrum was an appropriate food for their newborn and that colostrum would be harmful to their baby. They believe that if their newborn was fed colostrum, then their baby would suffer from stomachache, illness such as fever, and that their child will become “stupid.” The same study also reported that 74 percent of mothers offered supplementary liquids besides breastmilk within the first 7 days, and this practice continued until 6 months of age (Inayati et al., 2012). Delayed initiation of breastfeeding in Indonesia was associated with higher wealth quintiles, as infants from wealthier households had significantly increased odds of delayed initiation compared to those of lower wealth quintiles. Other factors associated with delayed initiation of breastfeeding were being from the Sumatera region, having a Caesarean section birth, and deliveries in government-owned and a non-health facility (Titaley et al., 2014).


Exclusive Breastfeeding WHO and UNICEF recommend that children be exclusively breastfed during the first six months of life. Indonesia shows some success in increasing the prevalence of exclusive breastfeeding 0-6 months—the 2017 IDHS preliminary report indicates that overall 51.5 percent of infants under six months in Indonesia are exclusively breastfed. The target of the 2015-2019 Ministry of Health Strategic Plan was to reach 50 percent national coverage of exclusive breastfeeding of infants less than six months. According to the SUSENAS 2015 data, only nine provinces have reached the target of the 2015 Strategic Plan (Figure 7) (Indonesia Ministry of National Development Planning and the United Nations Children’s Fund (2017).

Indonesia has provided laws and regulations to support exclusive breastfeeding. The 2003 Labor Law gave three months of paid maternity leave to working mothers. At least 1.5 months of this maternity leave must be taken after the birth of the child. The law also stated that employers must provide opportunities to breastfeed during working hours. In 2016, Aceh province introduced six months of paid maternity leave for female civil servants (The Straits Times, 2016). Maternity Leave is important in assuring that mothers can be employed in the formal sector and still ensure their babies are exclusively breastfed for six months. Maternity leave duration in Indonesia is about average among Southeast Asian countries. Two countries, Vietnam and Mongolia, offer more than 17 weeks paid maternity leave. For Vietnam, paid maternity leave was extended from four to six months in 2012 (Alive & Thrive, 2014). Brunei, Singapore and Japan have between 14-17 weeks of paid maternity

Figure 7. Coverage of exclusive breastfeeding on 0-5-month-old infants by province, 2015

0 10 20 30 40 50 60 70 80

Kepulauan Bangka Belitung

Sumatera Utara

Aceh

Kalimantan Barat

Riau

Papua Barat

Kalmiantan Tengah

Maluku Utara

Jawa Timur

National

Bali

Kalimantan Timur

Papua

Lampung

Jawa Tengah

Sulawesi Barat

Nusa Tenggara Timur

Nusa Tenggara Barat


leave. In Cambodia, East Timor, Indonesia, Laos, Myanmar, and Thailand maternity leave is for 12-13 weeks. Hong Kong, Malaysia, Papua New Guinea, and Philippines provide less than 12 weeks of maternity leave (UNICEF and Alive & Thrive, 2016).

Indonesia enacted another law in 2009 that promoted exclusive breastfeeding. It called for every infant to be breastfed or be given breastmilk from donors or milk banks exclusively for the first six months. Health Law No. 36/2009 Article 128 states in part: “(1) Every child has the right to receive breastmilk exclusively from birth for a minimum of six months, unless there is a medical indication to the contrary. (2) During the breastfeeding period, the family, the government, the local government and the community must give full support to the mother’s infant by providing time and special facilities” (Indonesia, 2013) However, enforcement of provision for special facilities is weak (Euromonitor International, 2013). A 2014 compliance report, for example, documented that only 12 out of 67 garment factories in the Greater Jakarta Area provided facilities, policies, or procedures for breastfeeding breaks.

Data from the 2012 IDHS found that older mothers were more likely to exclusively breastfeed compared to younger mothers; that mothers with higher education were more likely to exclusively breastfeed; unemployed mothers were more likely to exclusively breastfeed; and mothers with a high wealth index were less likely to exclusively breastfeed. Finally, mothers in Eastern Indonesia were more likely to exclusively breastfeed compared to those who lived in Sumatra and Kalimantan. Eastern Indonesia is more rural, less developed (Lenggogeni, 2016). This regional difference, however, was not found in a study using 2013 RISKESDAS data described in the section below.

Barriers to Exclusive Breastfeeding A WHO brief published in 2014 states that challenges to exclusive breastfeeding in Indonesia show that “a lack of knowledge and sociocultural, economic, and personal reasons mean that many women choose to bottle feed” (WHO, 2014). For example, a 2007 Save the Children survey in Aceh Province found that only 27 percent of mothers there knew the correct period of exclusive breastfeeding (Gallardo-DeGregorio, 2007). Another barrier mentioned is that community-based workers and village health centers (Posyandus) are not covered by regulations that protect exclusive breastfeeding that only apply to formal health care workers. The brief also states that breastfeeding decisions in general are influenced by family members, often grandmothers, and by health care workers (WHO, 2014a). Ideas from family members are closely related to the practice of feeding foods/drinks to infants younger than six months. Giving food such as bananas, honey, softened dates, sweetened condensed milk, sugar water and rice flour is still popular in rural areas (Dewi et al., 2016).

Work is another barrier to exclusive breastfeeding. The 2012 IDHS reported that 55 percent of all women aged 15-49 were employed. The data indicated that of those employed, 20 percent of women worked in agriculture, 36 percent were in sales and services, and one quarter were employed in the industrial sector (Statistics Indonesia, 2012). A study using the 2012 IDHS survey data looked at the relationship of working mothers to exclusive breastfeeding. Mothers who are employed have a lower chance of exclusive breastfeeding. Full-time working mothers were 1.54 times likely not to be able to exclusively breastfeed than unemployed mothers. The following workplace barriers were found to impede exclusive breastfeeding:

• Lack of private lactational areas;• Lack of flexible working schedules;• Bad relationships with employers or supervisors;• Declining productivity; and• Financial concerns (Carlson, 2008).


When women must return to work, particularly in agricultural work, they often leave their infant in the care of a family member who gives breastmilk substitutes. Those in a more formal work position may be no better off. Although the 2009 law mandated that employers provide places for female workers to breastfeed their babies during working hours, a study by Save the Children and the Indonesian Breastfeeding Mothers’ Association in 2011 reported that only 10 percent of government offices and 11 percent of private offices provided those places. (Save the Children, 2013). Working mothers who are not provided with lactational facilities must often use toilets or female prayer rooms and store milk in the pantry refrigerator along with the food and beverages of other workers (Sari, 2016). Flexibility of working hours or a range of break times is needed for nursing mothers. Companies need to accommodate nursing mothers for variable break times which could potentially put them at odds with other employees who must follow a strict schedule.

A cross-sectional study performed among female employees with children under three in three governmental offices and two factories in Jakarta showed that a proper dedicated breastfeeding facility was available for 21.5 percent of the mothers, but only 7.5 percent had been in contact with a breastfeeding support program. The presence of a dedicated breastfeeding facility increased exclusive breastfeeding practice almost threefold. Knowledge of the breastfeeding support program increased exclusive breastfeeding practice by almost six times (Basrowi et al., 2015).

A case report found multiple external and internal factors that prevented mothers from exclusive breastfeeding, one of which being working outside the home. Internal influences include poor knowledge, inadequate skills, such as positioning and latching on, motivation, and lack of confidence. Also, support from the facilitates improves exclusive breastfeeding, but a lack of such support has been shown to be a barrier (Februhartanty et al., 2012).

A secondary analysis of data from an exclusive breastfeeding promotion in Demak district, Central Java, found that grandmothers’ lack of support, receiving formula samples from midwives at hospital discharge, and maternal breast engorgement were all factors that shortened the period of exclusive breastfeeding. Mothers having increased breastfeeding knowledge was the only factor associated with longer duration of exclusive breastfeeding (Susiloretni et al., 2015).

Interviews with opinion leaders in Indonesia have reported that the commitment of some health workers in encouraging breastfeeding is still low (Dewi et al., 2016). They attributed this low commitment to the relationship that the BMS companies have cultivated with some health workers. For example, BMS companies organize seminars/training sessions for health workers influencing health workers’ interest in encouraging breastfeeding among mothers. Midwives participate in these seminars/training sessions so that they can obtain certificates that can boost job promotions, or to obtain a five-year license to open a practice without having to do a competency test. Rewards and gifts from BMS companies are additional motivations for midwives to purchase more BMS products as well as instructions from the health workers’ association to collaborate with BMS companies (Dewi et al., 2016).

A study to determine the relationship between the timely initiation of breastfeeding and the practice of exclusive breastfeeding using RISKESDAS 2013 data found that infants who receive early breastfeeding initiation have a higher likelihood of being exclusively breastfed. Children who are ill during the first 28 days of life or during the neonatal period are less likely to receive exclusive breastfeeding, often because mothers who had infants with medical conditions tended to stop breastfeeding during the illness. Sometimes this was because breastmilk was thought to be the source of the fever. Other factors, such as mother’s education and age, child’s birthweight, household economic status, and residential location were not associated with exclusive breastfeeding history (Paramashanti et al., 2016). An older 2007 survey set in 10 targeted tsunami-affected sub-districts in Aceh Province found that while 95 percent of children aged 0-11 months


were breastfed, only 35 percent practiced exclusive breastfeeding for infants under six months. Only 27 percent knew the correct period for exclusive breastfeeding (Gallardo-DeGregorio, 2007). The 2015 data indicated that the rate of exclusive breastfeeding for infants under six months had not improved and was at 33 percent for Aceh province (Indonesia Ministry of National Development Planning and the United Nations Children’s Fund, 2017).

Continued Breastfeeding IYCF practices promote the timely initiation of feeding solid/semisolid foods at 6 months of age, while maintaining frequent breastfeeding. The minimum IYCF practices for breastfed children age 6-23 months are defined as continued breastfeeding, and a minimum of two or three feedings of solid or semi-solid foods per day for infants depending on age in months. In Indonesia, according to the 2012 IDHS, the mean duration of exclusive breastfeeding is 3.7 months. The overall duration of any breastfeeding is 21.4 months and the mean duration is 20.5 months. IDHS data indicated that 77 percent of infants continue to breastfeed at one year and 55 percent of children are breastfed at two years.

Median duration of breastfeeding varies by province with the IDHS reporting a low of 9.4 months of any breastfeeding in Riau Islands Province to a high of 29.7 months of any breastfeeding in West Kalimantan (Statistics Indonesia, 2012). A 2012 study looking at feeding practices of mildly wasted children in Nias Island, North Sumatra Province, found that only 10 percent of children were breastfed at least two years (Inayati et al., 2012).

Many factors can affect whether a mother continues to breastfeed or stops. Formative research in Sidoarjo, East Java, a peri-urban area with poor child nutrition, reported that continued breastfeeding patterns there were related to confidence or lack thereof on the mother’s part; feeding was primarily child-led; and mothers faced pressure from family, friends, and neighbors to try to stop crying babies by any means necessary to avoid judgment of the mother’s skills. Children were frequently given snacks of biscuits, deep-fried snacks, crisps or “krupuk”. Child-rearing was often described as communal with family and friends influencing the feeding of young children. The mother, for example, was not always aware that grandmothers, aunts, neighbors and older children were giving the infants other foods (GAIN 2014).

The ability to continue breastfeeding is often affected by early difficulties the mother faces or by lack of support from family and healthcare providers. In a 2016 qualitative study, 14 pregnant women in West Jakarta were interviewed at three time-points – week 36 of pregnancy, one week after delivery and one month after delivery -- to determine factors affecting breastfeeding intention and continuation. Reasons given for women wanting to continue to breastfeed were: mother’s positive emotions and feelings, positive influences from other people, encouragement from parents, support and help from healthcare providers, and support from husbands. Reasons given by women who stopped breastfeeding or who supplemented breastmilk included: perceived obstacles (“Baby is restless”), mother’s feelings and emotions (“I feel groggy and numb”), negative influences from family members (“My mother-in-law said if I exclusively breastfeed . . . my baby will be hungry”), sore nipples and breast engorgement, lack of skills, formula samples provided by clinics, discouraging words from relatives, beliefs regarding breastfeeding (“You know, I have small breasts”), and early complementary feeding practices (Paramashanti et al., 2016).

Breastmilk Substitutes (BMS) Improving rates of breastfeeding and continuation of breastfeeding depend on, among other things, reducing the use of formula for infants and young children. IDHS 2012 survey data indicate that more than one-third of breastfed children under 2 months were given formula for infants and young children. Percentage of infants age 0-23 months who were bottle-fed was 37 percent. Bottle feeding


is associated with increased risk of illness, especially diarrheal diseases because of the difficulty in sterilizing the nipples properly. Bottle feeding also increases the risk of pregnancy for the mother as it shortens the period of amenorrhea. When children are not exclusively breastfed for six months, they are more susceptible to diarrhea and pneumonia, the two leading causes of childhood death worldwide (Alive & Thrive 2016). Breastfeeding is nutritionally, immunologically, neurologically, endocrinologically, economically, and ecologically superior to BMS, and does not confer the environmental risk of contamination associated with BMS and untreated water sources (WHO 2016c).

In addition to the risk of infant illness and the mother losing lactational amenorrhea protection, the use of substitutes is expensive. A 2015 report on the economic costs of not breastfeeding reported that the cost of BMS to a family in Bandung City during the exclusive breastfeeding period can reach as high as 37 percent of family income if there is no breastfeeding and 28 percent if there is partial breastfeeding (Siregar & Pitriyan, 2015). Many poor families who use formula or BMS can barely afford to do so. Because of this financial burden, families will dilute the BMS that they buy by adding water to each bottle. The water added to each bottle or mixed with the powder is often not clean. As a result, the infant is not only denied the greater nutritional value of breastmilk, but often suffers from severe cases of diarrhea and dehydration (Carlson, 2008).

Reasons for using BMS can vary. For instance, a mother who needs instruction on how to breastfeed may feel that she cannot produce enough milk for her infant either because, for example, she is using an oral contraceptive or because she is not eating enough herself (Carlson, 2008). Some mothers report seeing commercials that they believe say formula milk is better (Ng et al., 2012).

In a secondary analysis of 2007 IDHS data, it was found that of women who delivered in health facilities (43 percent) had a higher prevalence of bottle feeding than those who delivered at home (24 percent). This may be because wealthier women, who are more likely to bottle feed are also more likely to deliver in health facilities, or that health facilities do not give appropriate counsel on early and exclusive breastfeeding (Ng et al., 2012).

Disasters can also contribute to the use of BMS. After the 2006 earthquake in Yogyakarta, the initial recovery response included distribution of large quantities of BMS without regard to whether the household had been using BMS before the earthquake or not. A survey of households one month after the earthquake showed no attempt to limit the distribution of BMS according to pre-existing feeding practices or to households with older infants or to those where infants were no longer being breastfed. The study reports that IYCF practices changed as a result. Before the earthquake 32 percent of infants under 6 months had ever consumed BMS versus 43 percent afterwards. Diarrhea prevalence was 25 percent among those who received BMS donations versus 12 percent among those who did not. The authors suggest that the children were at risk because of lack of clean water and/or poor sanitation (Hipgrave et al., 2012).

Manufacturers and Distributors of BMS and Related Legislation

Barriers to exclusive breastfeeding can lead to the use of BMS. Economic growth and increasing disposable income have attracted companies to market their BMS products to mothers to feed their children. Indonesia is the fourth most populous country in the world and almost a million babies are born each year. Large BMS companies eye this huge market and push BMS products. In 2013 the market in Indonesia was estimated to be $1.1 billion and two-thirds of the BMS companies see their growth in the Asia Pacific region (Williams, 2013).

Euromonitor International is the world’s leading independent provider of market research. This quote from a Euromonitor International report on the status of BMS in Indonesia as of 2012 reflects the attitude of formula companies:


“The aggressive campaign by non-profit organizations to promote exclusive breastfeeding in the country is contributing to slowing down volume growth of milk formula in 2012. Further, the higher price increase of many baby food products in 2012 is prompting less purchasing of baby food by lower-income consumers. A number of consumers who have weaker purchasing power prefer to breastfeed their babies and to give their toddlers baby food products less frequently or in smaller amounts” (Euromonitor International, 2013).

In a more recent market report, Euromonitor suggests that the Government of Indonesia through the MoH and other NGOs will continue to promote breastfeeding and this along with a declining birth rate will slow down the growth of BMS sales in Indonesia. However, even with a lower birth rate, the number of new births is deemed high and the report predicts continued positive growth in sales of BMS for infants and young children. From the report, the last sentence of this quote is particularly revealing regarding perceptions of breastmilk versus BMS: “The rising popularity of breast-feeding is contributing to the slowdown in volume growth of baby food in Indonesia, which is dominated by milk formula. Breastmilk is widely perceived by most Indonesian families as the most nutritious option for babies, as well as being the cheapest. Breastfeeding is also believed to boost babies’ immune systems” (Euromonitor International, 2016).

Inappropriate marketing of BMS, which includes representing BMS as equal or superior to breastmilk and other misleading health claims, violates the WHO International Code of Marketing of Breastmilk Substitutes (called ‘The Code’) (Hidayana et al., 2017). The Code was first released in 1981. From 1982 through 2016 additional resolutions were adopted by the World Health Assembly that expand and clarify the Code; and for compliance purposes are considered part of it. The Code was developed to protect and promote breastfeeding and to prevent inappropriate marketing of BMS and related products (including bottles and teats) (Durako e al., 2016). The Code aims to shield breastfeeding from the commercial promotion of BMS that affects mothers, health workers and health care systems.

On its own the International Code is not legally enforceable, but an estimated 135 countries have some form of Code-related measures in place, an increase from 103 in 2011. Indonesia has many provisions of the Code in law as of 2012. Laws cover infant formula, follow-up formula, complementary foods, and feeding bottles, teats, and or pacifiers. Indonesian law also regulates the provision of free or low-cost supplies and materials and gifts to health care providers and also prohibits promotion to the general public through advertising, sales devices, as well as samples and gifts. There are also laws that apply criteria for monitoring code violations and the ability to impose legal sanctions (International Code of Marketing of Breast-milk Substitutes, 2017).

Information on, and the actual existence of, formal monitoring and enforcement activities are limited worldwide. Only 6 countries have a dedicated budget to monitoring and enforcement of laws related to Code. Indonesia has not fully implemented measures to protect exclusive breastfeeding. Code regulations are found in Indonesia Article 28 of Government Regulation Number 33 from 2012 on exclusive breastfeeding. It states, “Further provisions of the procedure for use of infant formula and other baby products shall be regulated by the Minister’s Regulation.” To implement provisions from that article, the MoH stipulated Regulation 39 on Infant Formula Milk and other Baby Products. The age range considered in the regulation is 0-12 months and prohibits promotion of BMS for children within that age range (Hidayana et al., 2017).

Unfortunately, community-based workers and village health centers or posts called “Posyandus” are not covered by the regulations preventing inappropriate marketing of BMS within the healthcare system. Based on the literature, it is unknown why this is. These Posyandus are almost always women providing services related to monitoring mother and child health, nutrition, immunization,


diarrhea control and family planning. They are set up once a month and can be an important delivery platform for counseling mothers on breastfeeding (Diana et al., 2017).

Nestlé and Danone are the two largest companies selling formula in Indonesia. Nestlé is the world’s largest food company accounting for 23 percent of the global baby nutrition products. Danone is the second largest. In 2007 Danone purchased Sari Husada, a BMS company in Indonesia which had been cultivating relationships with midwives through its ‘Srikandi’ programs. These Srikandi programs provided midwives with money and foreign travel in return for selling formula. Up until 2011 the midwives would sign a contract that would involve selling a certain number of boxes of formula a year. This is a violation of the Code and Indonesian regulations. Danone has since stated that this program has been discontinued and replaced by a training scheme for midwives. This training was called ‘Srikandi Academy’ and the aim was to “help junior midwives establish practices in rural areas” (Hidayana et al., 2017). But a Danone business case for the project in 2012 reported that health care professions, especially midwives, were key endorsers/brand ambassadors of their products. Targeting of health workers is against the Code (WHO, 2014). Since 2012, the Danone company, however, has also given gifts rather than money to the midwives. The gift may be for personal use or it may be for needed equipment for the midwife’s practice such as an oxygen canister or nebulizer (WHO, 2014).

There have been some attempts to measure compliance with the Code in Indonesia. A study conducted in November 2012 through February 2013 to measure compliance with the Code interviewed a total of 874 women (382 pregnant women and 492 breastfeeding mothers of infants age < 6 months) and 77 health workers from 18 participating public and private health facilities in six provinces on Java Island. The study found that 20 percent of women had received advice and information about BMS and 72 percent had seen promotional materials for BMS. About 15 percent reported receiving free samples from health workers or from company staff, and 16 percent received gifts such as bibs, nappies, toys or other gifts. Almost a quarter of health care staff reported receiving visits from formula companies. Two staff reported receiving gifts from the company (Hidayana et al., 2017). It is against the Code for BMS manufacturers or distributors to give free product samples to mothers or to give material or financial inducements to health workers (International Code of Marketing of Breast-milk Substitutes, 2017).

A scan of mass media and social media channels in Indonesia was conducted for six months from January to June 2015 to assess breastfeeding promotion and marketing of products covered by the Code, identify where and when violations or circumventions were occurring and to make recommendations. No violations of the Code in direct marketing of BMS for children less than 12 months were found. However, there were 107 advertisements, two-thirds of which were for BMS for children under 24 months which were in violation of the Code (Oslo and Arkershus University College of Applied Sciences & Alive & Thrive, 2015).

A study looking at compliance with provisions of the Code, subsequent WHA resolutions, and national measures by BMS manufacturers and distributors in Indonesia was conducted in May through August 2015 in Jakarta. Interviews were conducted with mothers and pregnant women and health workers; evaluations were done on promotional and educational materials found in health care facilities visited for interviews; evaluations of any marketing and promotions within selected retail stores; and evaluations of product labels and inserts of available products; and monitoring of selected media. A full description of the results of this study are beyond the scope of this desk review, but in general non-compliance appear to be limited. The key findings are: 1) items that appeared to be informational or education materials about infant feeding produced by BMS manufacturers or distributors were identified in 12 different health facilities and in different retail outlets. None of these items complied with the Code. 2) Only 2 health workers reported donations,


one of leaflets and one of posters/calendars although it is possible healthcare workers would not report donations. 3) media monitoring identified 495 unique ads for BMS products many of which ran multiple times on multiple outlets such as television station. 4) Of the 856 women interviewed, only 20 said they had received free samples of any BMS products. There was low incidence of self-report of having been offered samples (Oslo and Arkershus University College of Applied Sciences & Alive & Thrive, 2015; Vinje et al., 2017).

3.7. Complementary Feeding — Children 6–23 Months

Complementary Feeding Overview The WHO recommends nutritionally adequate complementary feeding (CF) through the introduction of indigenous foodstuffs and local foods while breastfeeding for at least 2 years, starting at approximately six months of age (WHO, 2016). Complementary food should be both timely, meaning that all infants should start receiving foods in addition to breastmilk at the appropriate age of six months, and adequate, meaning that the foods that are introduced should be given in amounts, frequencies, and consistencies that adequately cover a child’s evolving nutritional needs (WHO, 2016b). According to the WHO, complementary feeding is the most deficient area of infant and young child feeding in Indonesia, leading to a high proportion of stunting (Laksono Trisnantoro et al., 2010).

Inability to introduce complementary foods in a timely and adequate manner can contribute to stunting during a time of rapid development between 6 and 23 months. A 2017 study of 230 breastfed infants assessed at 6 months and followed at 9 and 12 months of age in the Sumedang District, West Java, Indonesia, evaluated complementary feeding practices and their relationship to subsequent growth. Intakes of calcium, iron, zinc and riboflavin were below WHO recommendations and stunting and underweight increased respectively from 16 percent and 4 percent at six months to 23 percent and 11 percent at 12 months (Diana et al., 2017). In another study conducted in 2014 by the Indonesian Ministry of Health in 33 provinces to examine the adequacy of food intake, the Total Diet Study found that 6.8 percent of children aged 0-59 months had insufficient calorie intake while 23.6 percent of children of the same age had protein deficiency (Research and Development Agency, Ministry of Health, Indonesia, 2014).

Evidence from a review of the current literature regarding child feeding practices indicates that 52 percent of mothers have adequate knowledge of appropriate child feeding practices, including knowledge regarding the age of complementary food introduction and the appropriate food consistency, the use of local or manufactured complementary foods, the consequences of early complementary food introduction, consequences of early weaning, and signs of insufficient child food intake. Seventy-one percent of mothers had appropriate attitudes regarding these same indicators (Blaney et al., 2015). During this important transition period to a mix of breastmilk and solid foods between six and nine months of age, one-quarter of infants are not fed appropriately with both breastmilk and other foods (The World Bank, 2011). This can lead to deficiencies in key nutrients, including iron, zinc, and niacin, especially among those six to eight months, according to an analysis of the 2010 Basic Health Survey (RISKESDAS) (Fahmida et al., 2014).

Reasons for improper feeding practices among young children in Indonesia varies. One study from Depok, outside Jakarta, suggests that working mothers who have access to family caregivers showed a lack of confidence in performing child care and good food practices (including breastfeeding, scheduled feeding, monitored food intake, and purchase of health foods, among others), depending increasingly on caregivers (Roshita et al., 2011). This same study indicated that working mothers of underweight and obese children who had family caregivers were found to have low confidence in terms of food preparation, stating that their children had unregulated feeding schedules.


Early Complementary Feeding

Early Complementary Feeding Prevalence and Coverage Evidence from across Indonesia indicates that early complementary feeding (before six months of age) is prevalent. The 2012 IDHS showed that 50.1 percent of infants aged 4-5 months consumed solid and semi-solid foods (Figure 8 and Table 10 ). Early introduction of complementary foods is common among both breastfeeding and non-breastfeeding children. Mixed feeding is the most common early complementary feeding practice for infants under six months in Indonesia, and by two months of age, more than one-third of breastfed infants are also fed with infant formula. A sharp jump occurs between months 2-3 and months 4-5 for breast fed children regarding the introduction of any solid or semi-solid foods, from 17.8 percent to 50.1 percent. By 6-8 months of age, over 90 percent of breastfed children are eating complementary foods. For non-breastfeeding children, this jump occurs between the months of 4-5 and 6-8, from 62.8 percent to 96.9 percent. Overall, more non-breastfed children are being introduced complementary foods at an earlier age than breast-fed children, mostly in the form of infant formula and fortified baby foods (Statistics Indonesia, 2012).

Figure 8. Infant feeding practices by age, 2012

Source: Indonesia Demographic Health Survey, 2012


Liquids Solid or semi-solid foods

Age in months

Infant formula

Other milk1

Other liquids2

Fortified baby foods

Food made from grains3

Fruits, vege-tables rich in vitamin A4

Other fruits, vege-tables

Food made from roots/ tubers

Food made from legumes/nuts

Milk, fish, poultry5

Eggs

Cheese, yogurt, other milk products

Any solid or semi-solid food

BREASTFEEDING CHILDREN 0-1 34.5 1.5 1.5 6.9 2.7 3.0 0.8 0.6 0.2 1.7 1.1 0.0 10.0 2-3 24.4 0.1 2.6 12.1 3.9 2.9 1.5 0.9 0.4 0.5 0.6 0.5 17.8 4-5 22.6 1.5 9.5 35.9 16.7 12.3 4.0 2.6 1.8 1.7 2.9 0.2 50.1 6-8 23.5 3.2 34.0 59.5 47.8 44.9 15.7 15.3 13.6 20.9 18.9 2.9 90.3 9-11 30.9 5.3 49.7 43.8 83.2 68.4 28.5 36.5 31.4 48.2 41.3 7.6 96.4 12-17 24.9 8.7 59.4 23.0 90.1 82.7 29.0 35.7 35.9 56.6 53.4 8.1 97.5 18-23 27.2 23.0 67.4 11.9 94.8 81.7 35.1 41.5 44.7 68.8 61.0 11.0 97.8

6-23 26.3 10.5 54.1 32.1 80.8 71.5 27.6 32.9 32.5 50.3 45.5 7.6 95.8

TOTAL 26.5 7.8 39.9 28.3 59.9 52.8 20.3 23.9 23.4 36.3 32.9 5.5 76.0 NONBREASTFEEDING CHILDREN

0-1 75.7 11.5 6.5 16.5 5.1 5.1 5.1 0.0 0.0 5.1 5.1 0.0 16.5 2-3 94.4 7.0 8.1 32.7 11.1 3.6 1.9 1.8 1.8 0.5 0.0 0.0 42.3 4-5 88.5 17.4 14.9 45.3 16.8 14.2 0.9 9.5 0.7 2.9 2.1 0.0 62.8 6-8 81.4 10.4 35.8 61.0 63.6 58.2 26.0 21.5 15.9 29.3 22.1 7.0 96.9 9-11 85.1 8.2 56.0 44.1 90.1 81.4 39.2 36.1 24.6 57.2 47.9 10.5 98.8 12-17 79.4 15.4 62.7 25.0 95.0 86.5 37.1 44.4 45.7 67.3 58.9 12.6 98.6 18-23 52.4 24.7 68.8 11.5 91.5 83.5 33.1 37.2 43.8 71.9 62.4 13.3 96.8

6-23 67.7 18.3 62.3 24.4 90.0 82.0 34.6 38.0 39.4 64.8 55.8 12.1 97.6

TOTAL 69.5 17.9 58.0 25.5 83.4 75.8 31.8 35.2 36.1 59.4 51.2 11.1 93.6 Note: Breastfeeding status and food consumed refer to “24-hour” period (yesterday and last night). 1 Other milk includes fresh, tinned, and powdered cow or another animal milk 2 Doesn’t include plain water 3 Includes fortified baby food 4 Includes yellow squash, carrots, yellow or orange sweet potatoes, dark green leafy vegetables (spinach, kangkong, katuk, cassava leaf, and squash leaf), mangoes, papayas, jackfruit, cempedak, persimmon, yellow melon, and other locally grown fruits and vegetables that are rich in vitamin A 5 Meat includes liver, kidney, heart, or other organ meats.

A 2015 review of literature related to feeding practices among Indonesia children found that between 79 percent and 81 percent of children were introduced solid, semi-solid, or soft foods before six months of age, with a mean age of complementary food introduction at 4.4 months across studies reviewed (Blaney et al., 2015). Many very young infants received iron fortified baby foods. At age 4-5 months more than one-third of babies were being fed fortified baby foods (Statistics Indonesia, 2012). In speaking with mothers, 35 percent reported introduction of complementary semi-solid or solid foods at six months (Blaney et al., 2015). A report from a survey of 4,800 households that were food-insecure in four districts of West Timor, East Nusa Tenggara (ENT) found premature introduction (before six months of age) of complementary food practiced among almost 80 percent of mothers (Care & CWS, 2017). A 2008 report by Oxfam conducted in ENT province found that nearly 69 percent of caretakers of children reported that they introduced complementary foods to infants when they were less than four months old (Teshome, 2008). Evidence from Aceh Province and Nias Island found that the percentage of children receiving solid or semi-solid food increases gradually by age. More than two-thirds (67 percent) of children age 4-5 months were receiving solid or semisolid food (UNICEF, 2012).

Table 10. Percentage of youngest children under age 2 by type of foods consumed according to breastfeeding status and age, Indonesia 2012 (Source: Indonesia Demographic Health Survey, 2012)


Determinants of Early Complementary Feeding An analysis of 2007 IDHS data revealed that a high percentage of children age 6-23 months had been given solid, semi-solid or soft foods. There was a significantly lower percentage of children age 6-8 months introduced to these types of complementary foods from poor households, those with mothers or fathers with no formal education, illiterate or formerly married mothers, no use of ANC or postnatal check-ups, and residence in outer islands especially Kalimantan (Ng et al., 2012).

A 2012 cross-sectional, survey study of infant feeding practices in several districts of Nias Island in North Sumatra Province reported that infants were given complementary feeding too early: 79 percent of infants received complementary foods (solid, semi-solid, or soft foods) before 6 months of age. A perceived lack of supply of breastmilk was the main reason mentioned for the early introduction of complementary foods in the study area. The opinions of senior female members of the family, especially the paternal grandmother (“ina matua”), played an important role in the decision of mothers to introduce solid, semi-solid, or soft foods at an early age (Inayati et al., 2012).

Diet Diversity and Meal Frequency

Diet Diversity and Meal Frequency Prevalence and Coverage IYCF feeding guidelines for minimum practices first proposed in 1991 were revised by WHO in 2007. According to these revised guidelines, feeding practices for breastfed children age 6-23 months are defined as: continued breastfeeding; a minimum of two feedings of solid or semi-solid foods per day for infants age 6-8 months and three feedings for children age 9-23 months. For non-breastfed children, the criteria are: receiving infant formula and other BMS; a minimum of four feedings of solid or semi-solid foods per day; and the consumption of solid or semi-solid foods from at least four food groups. According to a government Landscape Analysis Country Assessment in 2010, there is inadequate complementary feeding among young children. Frequency of feeding is low and only 75 percent consume sufficient number of food groups.

The 2012 IDHS reports that only 75 percent of infants and young children, age 6 to 23 months who are not breastfed, consume a diverse diet with four or more of the food groups listed below, compared to just 51.8 percent of same-age children who are breastfed (Statistics Indonesia, 2012). This varies by province. The lowest performing areas for both breastfed and non-breastfed children include parts of Sulawesi, East and West Nusa Tenggara, and the islands of Maluku and Papua (Table 11). For most provinces, children who are breastfed between 6 and 23 months are reported to have less dietary diversity than those who are not, as breastmilk was not considered a food group in the 2012 IDHS.

Table 11. Percentage of youngest children age 6-23 months living with their mother who are fed at least four key food groups, as defined by the MoH, in low performing Indonesian provinces, 2012

Province 4+ food groups among breastfed children (%)

4+ food groups among non-breastfed children (%)

Indonesia 51.8 75.5 WNT 40.5 53.1 ENT 40.8 52.6 Southeast Sulawesi 29.0 71.1 West Sulawesi 24.0 36.6 Maluku 33.2 63.3 North Maluku 34.2 59.6 West Papua 25.0 49.6 Papua 33.6 62.6 Source: Indonesia Demographic Health Survey, 2012


The frequency of complementary feeding is a major weakness in Indonesia. A Landscape Assessment performed by WHO found that only 67 percent of those with children age 6 to 23 months in Indonesia are offered complementary foods the minimum times per age group per day in addition to breastmilk (WHO, 2010). The 2012 IDHS data indicate that only 37 percent of children age 6-23 months were fed according to the WHO revised IYCF recommendations. The percentage was lower for breastfed children (34 percent) than non-breastfed children (43 percent). However, the proportion of children 6-23 months who were fed according to all three recommendations increased with age going from 18 percent for children 6-8 months to 45 percent for children 18-23 months. The proportion was slightly lower for children in rural areas (31 percent) than in urban areas (43 percent) and male children were slightly lower (35 percent) than female children (38 percent) (Statistics Indonesia, 2012). Approximately 61 percent of breastfed children met their minimum meal frequency, as opposed to 79 percent of non-breastfed children across Indonesia. The lowest performing provinces are outlined in Table 12.

Interestingly, some provinces different significantly between minimum meal frequency for breastfed versus non-breastfed children. For example, while 48 percent of breastfed children in West Java received minimum meal frequency, 80 percent of non-breastfed children in the same province did (Statistics Indonesia, 2012). This may be due to differences in understanding what constitutes minimum meal frequency for each group among caretakers. This is supported by previous research in 2007 by Save the Children in Aceh Province, that found only 53 percent of mothers of children 6-23 months old gave their children diverse kinds of food (Gallardo-DeGregorio, 2007).

A recent study in Sumedang District of West Java found that dietary diversity at six months was low. Sixty-three percent of infants were consuming only one or two food groups at six months. The range of food groups rose at 9 and 12 months. Intake of selected micronutrients from complementary foods failed to meet estimated needs at all three time-periods (6, 9 and 12 months). Authors recommended that caregivers increase the consumption of animal sourced foods and fruits and vegetables to meet WHO indicators for minimum dietary diversity (MDD) (Diana et al., 2017).

The 2012 IDHS (Table 10) reports 11 percent of infants age 6-23 months who are breastfed and 18 percent of non-breastfed infants received other milk. Other milk includes fresh, tinned or powdered milk from cows or other animals. Consumption of other milk was highest at age 18-23 months among both groups. Also, the consumption of liquids other than milk and infant formula increases slowly with age among children age 6 months or older. Fifty-four percent of breastfed children and 62 percent of non-breastfed children age 6-23 months were receiving other liquids (not including plain water) besides milk and infant formula. Many infants received fortified baby foods. At 6-8

Table 12. Percentage of youngest children age 6-23 months living with their mother who are fed the minimum meal frequency, as defined by the MoH, in low performing Indonesian provinces, 2012

Province Minimum meal frequency,breastfed children (%)

Indonesia 61.4West Java 47.6Banten 54.9West Kalimantan 51.3 Maluku 53.0 West Papua 48.5Papua 42.0Province Minimum meal frequency, non-

breastfed children (%)

Indonesia 78.7 North Sumatera 59.7WNT 56.7ENT 46.4West Sulawesi 53.9North Maluku 56.8West Papua 51.2Source: Indonesia Demographic Health Survey, 2012


months about 60 percent of both groups of infants were being given fortified baby foods. Overall, 81 percent of breastfed children age 6-23 months consumed food made from grains, 72 percent consumed fruits and vegetables rich in vitamin A, 50 percent had meat, fish and poultry, and 46 percent consumed eggs (Statistics Indonesia, 2012).

In a nutrition and food security baseline survey conducted by Oxfam in ENT, about 55 percent of caregivers surveyed said they had fed their young children (ages 6 to 23 months) three times in the previous day. Eighteen percent indicated that they fed their child one to two times a day, 18 percent reported they had no food to feed their children, while 9 percent said they have fed their child more than three times a day. Based on these reports, children in this age group were fed significantly less frequently than children of older age groups. Besides eating less frequently, the dietary diversity of children in this survey was poor, consuming less protein and subsisting primarily on rice porridge and/or green vegetables (Teshome, 2008).

Diet Diversity and Meal Frequency Social Norms In an effort to improve dietary diversity among children 6-23 months, GAIN and the Indonesian Ministry of Health supported the evaluation of a mass media and community-based intervention trial, Gerakan Rumpi Sehat (the Health Gossip Movement), in Sidoarjo, East Java (White et al., 2016). The campaign was based on Behaviour Centered Design, which focused on messages that employed emotional drivers of behavior change (affiliation, nurture, disgust) as opposed to educational messaging. The evaluation consisted of a 2-arm cluster randomized trial with a non-randomized control arm. One intervention arm received TV ads only, while the other received TV plus community activations. Results showed that dietary diversity increased in both intervention arms, including an increase in the reported frequency of vegetable intake. However, despite these improvements, the average dietary diversity at end line was still less than the recommended four or more food groups per day. The intervention had no noticeable impact on unhealthy snacking behavior, although it did increase the intake of healthy snacks such as fruits. Results indicate that mass media can have a measurable effect on nutrition-related behavior change, but these effects are enhanced through complementary community activation (White et al., 2016).

Complementary feeding may also benefit from additional supplementation with nutrients. A 2016 study of 168 infants in rural West Madura Island, Indonesia, found that those who received a small quantity of lipid-based nutrient supplements had improved linear growth and reduced stunting over a 6-month period over those infants who were given 3 pieces of biscuits or no intervention (Muslihah et al., 2016). In West Java, infants consuming fortified foods had low diet diversity, but there was a positive subsequent growth that may have been due to a content of powdered cow’s milk and micronutrients (Diana et al, 2017).

Feeding During and After Illness and Addressing Poor Appetite According to the 2012 IDHS, 14.3 percent of mothers surveyed reported their children under five had diarrhea in the past two weeks. Approximately one quarter of child under five were reported to have diarrhea in the past two weeks, compared with just 7 percent in DI Yogyakarta. Sixty-six percent of children under five were treated with either oral rehydration therapy (ORT) or increased fluids during diarrhea. The 2012 IDHS report indicates that mothers are encouraged to continue feeding their children who have diarrhea as per usual and to increase their fluid intake. However, these recommendations are not often followed, with 40 percent of children reportedly given more fluids than normal, 43 percent given the same amount, and 17 percent receiving fewer or no liquids at all. Regarding food intake, only 10 percent of children received more food than usual during diarrhea, with 39 percent receiving the same amount, and 46 percent were given less or no food at all (Statistics Indonesia, 2012). A review on the literature regarding child feeding practices found that


9 percent of mothers surveyed believed that giving foods during illness will worsen it, and that children are less hungry when they are ill (Blaney et al, 2015). Limited literature addressed the specific topic of feeding during and after illness in children in Indonesia. More research needs to be done to understand the attitudes and drivers behind these practices.

3.8. Child Nutrient Intake

Nutrient Requirement Overview Organizations, such as the WHO, have established human nutrient requirements and recommended nutrient intakes. These recommendations become the basis of individual countries when they develop their own recommended dietary allowance (RDA) values. Essential nutrients, such as iron, calcium and vitamins, are needed by the body for normal functioning. These micronutrients cannot be synthesized by the body or are only produced in small amounts, and therefore must be provided through supplements or foods rich in these micronutrients, including calcium, iron, niacin, and zinc. Often, when complementary feeding is not introduced timely and/or is not adequate, children can become deficient in these key nutrients and are at an increased susceptibility of illness and developmental difficulty. Some studies suggest that is it difficult to achieve desired density for these nutrients in Indonesian complementary feeding diets, particularly due to factors such as physical or economic access or acceptability of nutrient-dense foods (Santika et al, 2009).

Not only is stunting a problem for children during their first two years, but many Indonesian adolescents do not have the opportunity to make-up these height differences during the growth spurts brought on by puberty. Indonesian 18-year-old girls have a 9.8 cm height deficit as compared with well-nourished peers. Among adolescents, studies have found anemia prevalences ranging from 22 percent–44 percent, which exceeds the WHO’s cut-off of 15 percent (Santika et al, 2009).

A study that used linear programming to develop complementary food recommendations and promote key nutrient intake among children in Lombok suggests that to overcome the cost constraints of feeding young Indonesian children nutrient-dense complementary feeding diets, additional affordable strategies to improve nutrient densities of complementary foods, particularly for iron and calcium, need to be considered, including home fortification, formulated or fortified complementary foods, and fortified staple foods (Fahmida et al., 2015).

Vitamin A Intake among Children Vitamin A deficiency can decrease the immune system and increase the risk of infant morbidity and mortality. Vitamin A deficiency is the leading cause of preventable blindness in children. According to the Guidelines for Administration of Vitamin A Supplements, vitamin A supplementation is given to all children aged 6-59 months simultaneously through Posyandus in February or August for infants aged 6-11 months and in February and August for children under five (12-59 months). Among children with a health card or health center record book (MCH Handbook) (69 percent), only 22 percent had received a vitamin A capsule in the last 6 months. In 2015, the coverage of vitamin A on infants aged 6-59 months in Indonesia was 83.5 percent, a slight decrease from 2014 (85.4 percent) (Statistics Indonesia, 2012). The 2014 GAIN report found that Indonesia had achieved a high rate of vitamin A supplementation, with 86 percent of children age 6-59 months having received the recommended two doses at six months apart. Of the 31 provinces submitting data for the 2015 Indonesia Health Profile, eleven provinces (35 percent) achieved 90 percent coverage of vitamin A (Appendix 9). The highest coverage of vitamin A supplementation on 6-59 months infants was DI Yogyakarta (98.8 percent) with North Sumatera achieving the lowest coverage (53.2 percent) (Statistics Indonesia, 2012).


The high coverage of vitamin A supplementation is partly due to geographical conditions and affordable access to the Posyandu in distributing vitamin A. The provinces with a high coverage of vitamin A supplementation are usually those with a high coverage of weighed under-fives in Posyandu. Likewise, some provinces have a low coverage of vitamin A supplementation, such as Papua and West Papua, due to the low level of public participation in weighing their children in Posyandu as well as due to geographical constraints. Vitamin A supplementation in the provinces of DKI Jakarta and North Sumatera is very low due to incomplete records and reports. Not all activities in these regions were reported for the 2015 Indonesia Health Profile (Statistics Indonesia, 2012).

The 2012 IDHS reports that 82.7 percent of Indonesian children age 6-23 months living with their mother consumed foods rich in vitamin A in the last 24 hours at the time of the survey. This ranges from 64.3 percent in North Maluku to 88.9 percent in the Riau Islands. The IDHS also reported significantly lower vitamin A supplementation than the 2015 Health Survey, with only 61.1 percent of children age 6 to 59 months given vitamin A supplementation in the past 6 months before the survey. According to this data, children age 6-8 months were markedly less likely to have received vitamin A supplements compared with older children. Children living in urban areas, those born to highly educated mothers, children of mothers age 20 or older at the child’s birth, and children in the highest wealth quintiles were more likely to have received vitamin A supplements than other children (Statistics Indonesia, 2012).

Iron Intake among Children About two-thirds (68 percent) of children age 6-23 months consumed foods rich in iron in the 24 hours preceding the 2012 IDHS, ranging from 50.8 percent in West Sulawesi to 78.3 percent in Jakarta. Unlike the consumption of foods rich in vitamin A, the consumption of foods rich in iron increases markedly with the mother’s education. Otherwise, the variations in children’s consumption of iron-rich foods by background characteristics are generally similar to those observed for consumption of vitamin A-rich foods. As of 2012, 13.6 percent of mothers of children age 6-59 months gave iron supplementation in the past seven days preceding the IDHS survey (Statistics Indonesia, 2012).

A cross section study among over 45,000 families in urban slums and rural areas suggests that maternal knowledge of anemia is associated with lower odds of anemia in children and with some health behaviors related to reducing anemia (Torlesse et al., 2016). Knowledge of anemia was defined based upon the mother’s ability to correctly name at least one symptom of anemia and at least one treatment strategy for reducing anemia. Hemoglobin was measured in both the mother and child. In urban and rural areas, 35.8 and 36.9 percent of mothers had knowledge of anemia, and 62.3 and 54.0 percent of children were anemic, respectively (UNICEF East Asia, 2016).

Zinc Intake among Children Zinc supplementation has been shown to benefit linear growth, combatting the effects of stunting. One study conducted in rural East Lombok, WNT investigated whether linear growth could be improved with zinc alone or in conjunction with other micronutrients (Fahmida et al., 2007). The study concluded that zinc only improved stunting if other micronutrient levels were sufficient. For example, initially stunted infants, particularly boys, only responded with improved linear growth when zinc was supplemented with iron. This was especially true among infants with low hemoglobin. The study also concluded that zinc deficiency was not nearly as significant a public health problem among this population as anemia or iron deficiency (Fahmida et al., 2007).


Macronutrients and Energy Intake among Children Inadequate intake of protein, especially on a long-term basis, leads to stunting and/or thinning. Results of the Southeast Asia Nutrition Survey (SEANUTS) from 2012 reports that in Indonesia, 45 to 74 percent of rural children and 28 to 57 percent of urban children had a protein intake below the local recommended daily amount (RDA) (Friesland Campina Institute (2012). Over half (54.2 percent) of children age 0-59 months received high protein sufficiency, with 11.5 percent receiving average, and 34.2 percent receiving low or severely low protein sufficiency (Statistics Indonesia, 2012).

Results of the SEANUTS show that more than half of Indonesian children in the urban and rural areas did not meet the dietary requirement for energy, except among urban children in the 6 to 11-month age group which were slightly below fifty percent (Friesland Campina Institute (2012). As children got older, they were more prone to have less energy intake. The national average energy intake for children aged 0-59 months was 1,137 kcal as of 2015, which is higher than the recommended energy intake of 1,118 kcal. Average energy intake in urban areas (1,190 kcal) was higher than that in rural areas (1,081 kcal). This amounts to an average energy sufficiency. More than half (55 percent) of Indonesian provinces has averagely normal energy intake levels for children aged 0-59 months, with the remaining provinces reporting averagely low energy intake for the same aged population. Jakarta reported the highest average energy intake level for this population (114.4 percent), with ENT reporting the lowest (92.3 percent) (Statistics Indonesia, 2012).

3.9. Nutrition-Sensitive Practices

Water, Sanitation, and Hygiene (WASH) Practices

WASH Overview Besides pre- and post-natal nutritional deficits, environmental enteric dysfunction (EED) and other enteric and systemic factors contribute to stunting and chronic malnutrition in children across Indonesia (Owino et al., 2016). EED is defined as a generalized disturbance of small intestine structure and function that is typically found at a high prevalence among children living in unsanitary conditions.

Diarrhea and undernutrition form part of a vicious cycle. Diarrhea can impair nutritional status through loss of appetite, malabsorption of nutrients and increased metabolism (WHO, 2015). Frequent episodes of diarrhea in the first two years of life increase the risk of stunting and can impair cognitive development. At the same time, undernourished children have weakened immune systems, which make them more susceptible to enteric infections that can lead to more severe and prolonged episodes of diarrhea (WHO, 2015). In order to combat EED and its effects, a combination of proper nutritional practices, as well as a reduction in exposure to feces and contact with animals through improved WASH practices is advised (Owino et al., 2016). These practices, including hand washing after using the bathroom, before food preparation and child feeding, access to clean water to prepare food with, and access to proper household sanitation facilities is of paramount importance to proper nutrition.

According to the most recent global burden of disease estimates, access to improved WASH could prevent 361,000 diarrheal deaths per year among children under 5 years of age globally, representing 58 percent of the total diarrhea deaths in this age group. This analysis also suggests that the greatest reductions in diarrhea mortality (up to 73 percent) can be achieved through services that provide safe and continuous piped water supply and through sewerage connections that remove excreta from both households and community environments (WHO, 2015). Another


analysis of 171 surveys in 70 low- and middle-income countries, including Indonesia, found that increasing access to and use of improved sanitation and improved water sources reduced the risk of stunting (Fink et al, 2011). This study did not disaggregate data to indicate specific indicators for Indonesia.

Effectiveness of WASH on Nutrition However, recent trials to test the effects of integrated delivery of specific interventions that address nutritional and WASH-related determinants of stunting suggests that improved WASH alone does not contribute significantly to stunting reduction (Menon & Frongillo, 2018). Evidence from cluster-randomized controlled trials in Kenya and Bangladesh assigned geographically-adjacent clusters to passive and active control groups as well as six combinations of counseling intervention groups aimed at stunting reduction. Results determined that those groups who had WASH interventions alone did not have significantly reduced rates of stunting as compared to the control. Those interventions that combined nutrition and WASH counseling had reduced stunting and diarrhea, but the evidence suggest there is no advantage of integrating WASH practices with nutrition counseling and supplementation. Therefore, to maximize WASH-related stunting, nutrition counseling and supplementation must be provided in tandem with adequate hygiene and sanitation (Null et al., 2018; Luby et al., 2018).

As of 2015, 87 percent of the population is using improved drinking water sources, and 61 percent are using improved sanitation (WHO, 2017a). WASH practices have greatly improved over the past decade in Indonesia, despite low levels of public investment in the WASH sector (UNICEF East Asia, 2016). This can primarily be attributed to individual household investments in wells, water boiling, and a growing reliance on bottled water (UNICEF East Asia, 2016). However, this varies considerably across provinces, with more rural and poor areas having less access to proper sanitation and clean drinking water (Statistics Indonesia, 2012). Areas with unimproved latrines and untreated drinking water have been associated with an increased odds of stunting, compared with areas that have improved conditions (Torlesse et al., 2016). The Government of Indonesia, as part of their Community Approaches to Total Sanitation and Hygiene, are utilizing a five-pillared approach that includes eliminating open defecation, increasing the practice of handwashing with soap and household water treatment, and improving solid waste and wastewater management (Hirai et al., 2016).

Food Hygiene and Safety Poor food-hygiene practices play a significant role in the development of diarrhea. There is evidence that children under-2 are especially vulnerable to effects of poor food hygiene. One cross-sectional study among children aged 12-59 months in low socioeconomic urban areas of Jakarta found that children living in a house with less dirty sewage had a significantly lower diarrhea prevalence compared to those who did not. Overall food hygiene was not significantly associated with diarrhea in the total group but was among children under-two (Augustina et al., 2013).

Another study which used structured equation models (SEM) describe the relationship between drinking water quality, environmental quality, household hygiene, and food hygiene among 1,000 children aged 1-4 years in low-income areas of Jakarta found that only food and household hygiene were significantly linked to diarrhea (Sima et al., 2013). The study also suggests that interventions targeting these and other indicators are more efficacious than those that target just one factor. These findings are similar to other findings that suggest the importance of surface decontamination. Data from a prospective study of childhood diarrhea rates in low-income areas of Jakarta, Indonesia were analyzed by using SEM and analysis showed that food hygiene and household hygiene practices


are significantly associated with diarrhea length, controlling for environmental quality and drinking water quality.

Bottle-feeding incurs additional food hygiene risks. One study investigated the levels of bacterial contamination in formula bottle feeding among households with children under-2 in Sidoarjo, East Java (Gibson et al., 2017). Caregivers were observed preparing bottles, and samples of formula were tested for E. coli. Additional in-depth interviews were conducted with a sub-set of caregivers. A total of 88 percent of the formulas were contaminated at levels defined as “unfit for human consumption”, with 45 percent containing E. coli. Video observation showed that no mothers complied with all five WHO recommended measures of hygienic formula feed preparation, and only two mothers washed their hands with soap prior to preparing formula. Most mothers also failed to clean and sterilize the bottle as well as the preparation space properly. In-depth interviews with mothers confirmed these practices, or lack thereof, were common (Gibson et al., 2017).

A qualitative study that investigated the food and personal hygiene practices in an urban area of Jakarta among caregivers whose children have diarrhea found that most mothers associated the importance of food hygiene with disease prevention, contaminating agents, and health (Usfar et al., 2010). Upon direct observation, mothers commonly wiped cutting boards with a kitchen towel after slicing vegetables, whereas they washed the board with soap and water after cutting raw meat. Mothers perceived that the importance of personal hygiene was for maintaining health and cleanliness (Usfar et al., 2010).

Handwashing at Critical Times Handwashing with soap at critical times, including before and after food preparation, before feeding children, and after cleaning child stools, can serve as a primary barrier against communicable diseases that contribute to child stunting and malnutrition (UNICEF East Asia, 2016; Hirai et al., 2016). The Government of Indonesia promotes handwashing with soap as part of the national sanitation program, and aims to eliminate open defecation from 20,000 villages by 2019(Hirai et al., 2016). As of 2015, over 26,000 villages are participating, representing over a quarter of all villages in Indonesia. Ninety-two percent of households use soap and water in the place most often used for handwashing. This varied significantly, with ENT and WNT having the lowest use of soap in their households, at 72 percent and 73 percent, respectively. As defined by the MoH, soap includes soap or detergent in bar, liquid, powder, or paste form. This coverage includes households with soap and water only as well as those with soap and water and other cleaning agents. Eighty-seven percent of urban households practiced observable handwashing in urban residences, with 96 percent of those who hand wash using soap and water. Rural areas found approximately 72 percent of residences are engaged in handwashing, with 89 percent of those instances using soap and water (Statistics Indonesia, 2012).

MCA Indonesia conducted formative research on hygiene and sanitation to inform its NNCC campaign and subsequent sanitation public service announcements (PSAs). Research concluded that, among the 10 provinces studied, soap was only available in 34.6 percent of households and only 23.6 percent of homes had running water. Surveys found good knowledge of hand washing with soap, but poor practice: 34 percent washed hands after defecation; 29 percent after child’s defecation; 73 percent before a meal; and 60 percent after a meal (IMA World Health, 2018).

A nutrition and food security report from ENT indicated that thirty-nine percent of respondents washed their hands before feeding their children, with 43 percent indicating they washed hands sometimes, and 18 percent saying they did not wash hands before feeding their child. The survey did not specify whether soap was used. Forty-two percent of respondents said they washed hands after defecating, with 39 percent sometimes washing their hands, and 19 percent who did not wash their


hands (Teshome, 2008). These suboptimal handwashing behaviors are supported by qualitative observation and in-depth interviews among mothers whose children suffered from recurrent diarrhea found that the majority of mothers washed their hands without soap after performing housework and cooking (Usfar et al., 2010).

Determinants of Handwashing. In a study which explored determinants of handwashing across rural NTT, South Sulawesi, and Papua, approximately 90 percent of respondents reported they washed hands with soap before eating, with only 16 percent saying they did so before cooking, 7.6 percent did so before feeding children, and 13.4 percent did so after cleaning a child’s stools (Hirai et al., 2016). Based on these results, the following behavioral determinants were significantly associated with handwashing: 1) a desire to smell good; 2) interpersonal influences; 3) the presence of handwashing places within 10 paces of the kitchen and the toilet; and 4) emphasizing key handwashing moments when hands feel dirty or sticky as self-reported by the participant (Hirai et al., 2016). This was found to be particularly salient for populations from low socioeconomic areas. Based on this research, utilizing non-health messages that relate to social desirability (smelling good, interpersonal influences) for health behavior modification may prove to be efficacious (Hirai et al., 2016). In another study conducted in Serang in Batan province, new mothers reported rarely washing their hands before food preparation, while serving others, or before eating (Greenland et al., 2013). In addition, targeting new mothers for these interventions may be useful in establishing key handwashing behaviors while a child is still young and mothers’ routines are changing to meet the needs of their new baby (Greenland et al., 2013. Targeting these messages at influencers who have direct contact with the baby and can serve to reinforce these behaviors among mothers, such as grandmothers and midwives, can amplify these messages within families. In both of these studies, washing hands after food preparation was the most or one of the most common times for a woman to wash their hands (Hirai et al., 2016; Greenland et al., 2013).

There is additional evidence that suggests handwashing behavior is also suboptimal among healthcare workers. A study conducted in two hospitals and eight clinics (both public and private) in a rural Indonesian district sought to understand the social and behavioral context of hand hygiene barriers (Marjadi & McLaws, 2010). Major barriers to handwashing compliance included longstanding water scarcity and tolerance of dirtiness by the community and the healthcare organizational culture. Hand hygiene compliance was poor (20 percent) and was more likely to be undertaken after patient contact (34 percent after-patient contact vs 5 percent before-patient contact). Clinicians frequently touched patients without hand hygiene, and some clinicians avoided touching patients altogether. This, combined with the above evidence, suggest a strong behavioral component to handwashing behaviors both at home and in healthcare facilities throughout Indonesia.

Sanitation Indonesia has the second largest burden of open defecation, next to India, with an estimated 51 million of its total population practicing open defecation (Cronin et al., 2016). An analysis of data from 140 demographic and health surveys (DHS) in 65 countries reported that over half of the variation in average child height between countries was explained by the frequency of open defecation (Spears et al., 2013).

According to the 2012 IDHS, households without proper sanitation facilities have an increased risk of diseases like diarrhea, dysentery, and typhoid compared to households with proper sanitation facilities. These diseases not only threaten the proper nutrition, but lives of babies and small children, as diarrheal diseases can quickly lead to an imbalance of micronutrients and electrolytes


and lead to rapid deterioration. As of 2012, 68 percent of households have a private toilet. A toilet is considered private if it is used by only one household. However, urban-rural differences are marked, with 80 percent of urban households having a private toilet for their residence, compared to just 56 percent of rural households (Statistics Indonesia, 2012). It is estimated that approximately 20 percent of Indonesia’s population still defecates in open spaces (UNICEF East Asia, 2016). The 2015 Health Survey indicates that 62 percent of households in Indonesia have proper sanitation. This varies between provinces, with ENT (24 percent), Papua (28 percent), Central Kalimantan (36 percent), and Bengkulu (39 percent) having the lowest coverage of proper sanitation (Statistics Indonesia, 2012).

Despite more than half of households across Indonesia having access to private toilets, in most areas of Indonesia fecal matter is discharged into open environments (UNICEF East Asia, 2016). Unsafe disposal of child feces is strongly associated with increased odds of diarrhea in children less than two, making it one of the few WASH practices to find such a strong association, according to IDHS data (Cronin et al., 2016).

The percentage of children whose stools are disposed of safely is only 60 percent across Indonesia, according to the 2012 IDHS, with areas in Maluku and Papua (29 percent to 38 percent), Gorontalo (29 percent) and West Sulawesi (29 percent) having the lowest prevalence of safe disposal of children’s stools. Children’s stools are considered to be disposed of safely if the child used a toilet or latrine, if the fecal matter was put/rinsed into a toilet or latrine, or if it was burned (Statistics Indonesia, 2012).

In a nutrition and food security baseline survey conducted in ENT, more than half (64 percent) of households were using drinking water from safe sources such as tap water and protected wells and springs (Teshome, 2008). Almost 90 percent of surveyed households have access to toilet facilities of some kind. Seventy-one percent disposed their child’s feces immediately and hygienically, although how this indicator was defined was not presented (Teshome, 2008).

Early Childhood Development and Community Practices Stunting and chronic malnutrition have been associated with cognitive delays and developmental impairment (Ruel & Alderman, 2013; Chang & Hasan, 2012). The brain is most responsive in the first three years of life. This is when it grows and develops fastest. Parenting plays an important role in optimal child development, especially patterns of nutrition and psychosocial stimulation that are established from an early age. Stimulation includes play activity that are sustained to stimulate the left and right brain through all senses and to stimulate the ability to think, communicate, emote, and enjoy music as well as a variety of other infant capabilities. Psychosocial stimulation includes educational stimulation to develop cognitive, physical, and motor and social-emotional abilities of children (Warsito et al., 2012). Investment in high quality early childhood education (ECD) services prior to entering school improves learning outcomes for children. It also enhances the efficiency of the school system by reducing repetition and drop-out and improving achievement, especially among girls and marginalized groups (UNICEF, Early Childhood Development).

There is an increasing amount of evidence from low resource settings that programs to improve infant stimulation and enhance parenting have a beneficial effect on children’s long-term mental health. They have additive effects when combined with nutrition programs. They improve children’s growth and developmental outcomes in the long term (Jones, Guidance note for integrating ECD activities into nutrition programmes in emergencies).

A 2012 study of preschool aged children in West Java showed that psychosocial stimulation, participation in ECD, and nutritional status based on the height index for age had a positive and significant effect on cognitive development of children this age (Warsito et al., 2012). The


psychosocial stimulation dimensions that were positively correlated with cognitive development were learning stimulation, academic stimulation, and stimulus variation. In addition, children whose mothers had a higher educational level and were from families with higher socioeconomic status had higher development scores. Specifically, mothers with a high level of nutritional knowledge had children with greater cognitive development than those with a low to moderate level of nutritional education (Warsito et al., 2012).

In a 2015 study to improve knowledge, practices and intakes of key problem nutrients in Lombok, Indonesia, psychosocial stimulation in addition to complementary feeding recommendations were implemented among mothers during home visits. The complementary feeding recommendations as well as psychosocial stimulation significantly increased intakes of calcium, iron, niacin and zinc. However, nutrient densities were still low (Fahmida et al., 2015). A second 2015 study in West Sumatera among 40 villages as part of a community-based randomized control trial looked at the effect of food supplementation and psychosocial stimulation on growth and cognitive development. The infants were divided into 4 groups: 1) Food Supplementation (FS); 2) Psychosocial Stimulation (PS); 3) Food Supplementation and Psychosocial Stimulation (FS+PS); and 4) Control Group (CG). The food supplement group comprised of local food sources and adjusted for local habits. In the three-arm study, there was improvement in linear growth and cognitive and motor development in infants in the food supplement and food supplement plus psychosocial stimulation intervention groups compared to the control group (Helmizer et al., 2017).

Programs to Address Early Childhood Development In 2015, 96 percent of children aged 6 were participating in organized learning activities through either early childhood development programs or primary school. However, the 2015 SUSESNAS data report that among the six-year-old population, 72 percent had attended early childhood development programs in the previous year or the year before. This shows that about one in four children had no experience with early childhood education (Indonesia Ministry of National Development Planning & the United Nations Children’s Fund, 2017).

The World Bank reports that, among 738,000 children ages 0 to 6 years and their parents/caregivers within 50 selected districts throughout Indonesia, children are most vulnerable in regard to three ECD domains: emotional maturity, physical health and well-being, and language and cognitive development (Chang & Hasan, 2012). This was attributed to limited stimulation at home, including reading books, or exposure to music, singing, and dancing in the home. Interventions combining nutrition and early childhood development can have moderating effects on both outcomes. The integration of both could enhance overall outcomes programmatically (Ruel & Alderman, 2013). Caregivers should be encouraged to interact with their infant for the development of motor skills and emotional well-being of the infant.

UNICEF reported on ECD project field experiences in Indonesia, where they addressed the early identification and support to families and children with special needs using Posyandus, where families already receive nutrition-based care (UNICEF, 2006). Existing integrated services were expanded to include early child brain stimulation through age-appropriate learning activities as well as health and nutrition. A pilot neighborhood playgroup was established for three to five-year-old children in 14 villages. Follow-up home visits for children with developmental or other delays were also included. Early results suggested high parental acceptance and attendance. Part of the success of this intervention is attributed to Indonesia’s long-established commitment to the concept of Community-Based Rehabilitation (CBR) for children with disabilities. These CBR programs, established in the 1980’s, included prevention and early identification of childhood disabilities as integral to ECD (UNICEF 2006).


World Vision implemented a holistic and integrative approach to ECD in Central Sulawesi, that integrated early childhood institution with all stakeholders, such as integrated health post, local government, churches and local office, as well as parents (Silitonga, 2015). Child development and disease management trainings that aligned with local context were held by early childhood cadres and health officials, including trainings by doctors to parents. Health officials remained heavily involved throughout the program, from health services provisions, such as child weighing and monthly inspection of teeth and fingernails, to examining the need for medicine.

Program Keluarga Harapan (PKH) is a conditional cash transfer providing direct cash benefits conditional on household participation in locally-provided health and education services (The World Bank, 2012). Like conditional cash transfers (CCTs) the world over, disbursements are made only after a mother’s verified attendance at pre- and postnatal checkups, a professionally-attended birth, newborn and toddler growth monitoring and health checks; or after verification that a PKH household’s school-aged children have good attendance records at their schools (whichever applies to a household). PKH children stayed in school longer, but PKH did not lead to increased enrollment rates for very poor households or significant reductions in child wage labor. PKH was successful in increasing the number of hours spent in school of those enrolled in either primary or junior secondary school. PKH did not change already high enrollment rates in basic or junior secondary education, nor did it reduce already low drop-out rates. The lack of effect on enrollment is likely due to very high initial rates of enrollment combined with a benefit size that is much less than the average cost of a year in the public schooling system and an initial schedule of payments that did not synchronize with the school fee cycle (The World Bank, 2012).

Although the PKH started in 2007, it was not until 2014 when the family development session was introduced into the PKH program. The family development session includes monthly education sessions for mothers that are facilitated by a PKH community worker to improve mothers’ knowledge on education, health, nutrition and financial management. The health and nutrition modules include: child stunting; the importance of the first 1,000 days as the foundational period for a child’s healthy growth and brain development; nutritional needs for pregnant women; the importance of antenatal care; delivery and post-partum information; breastfeeding; complementary feeding; the use of toilets and handwashing with soap; as well as the management of child illnesses (Kementerian Sosial Republik Indonesia, 2016).

Limited literature exists on early childhood development interventions and practices for children under two in Indonesia. Other reports on ECDs, such as those from UNICEF, do not have data regarding key ECD indicators, including wealth disparities for attendance in ECD, adult and paternal support for learning, learning materials at home, and children with adequate supervision (Rogers, 2017). These gaps in data must be filled in order to understand the state of ECD among Indonesia’s children and provide programmatic recommendations that contribute to meaningful change.

3.10. Recent MIYCN Formative Research and National Nutrition Communication Campaign in Indonesia

IMA World Health Formative Research and NNCC Campaign (2015-2018)

Objective The Government of Indonesia, with support from Millennium Challenge Account (MCA) Indonesia and Interfaith Medical Assistance (IMA) World Health, identified the need for a coordinated and targeted SBCC campaign that would apply a mix of mass media and interpersonal communication (IPC) to promote and support improved nutrition and sanitation at the national level in Indonesia,


with the ultimate goal of stunting reduction. Prior to the campaign, IMA World Health in partnership with the University of Indonesia’s Center for Nutrition and Health Studies conducted formative research so as to use the findings to inform the campaign.

The objective of this research was to understand knowledge, attitudes, and practices surrounding nutrition-related issues, particularly stunting, to inform the selection of priority behaviors to be promoted through the SBCC campaign. These issues included (IMA World Health, 2018):

1. Food consumption patterns of pregnant women, lactating mothers, and children under two. 2. Patterns of child care practices 3. Patterns of hygiene and sanitation practices 4. Patterns of media consumption

Methods Data was collected in 2014 from pregnant women, mothers of children under 2 years, family members, health workers, informal leaders, and district officials in 11 districts in the provinces of South Sumatera, West Java, East Java, West Kalimantan, Central Kalimantan, West Nusa Tenggara, East Nusa Tenggara, Maluku, North Sulawesi, and Gorontalo. This was done through a combination of surveys, focus group discussions, and in-depth interviews (IMA World Health, 2018). Results of the study are specified throughout this desk review as they relate to certain topics. In general, the results are in-line with national level data collected through the IDHS or RISKESDAS.

Results Results are summarized in Table 13, including uptake of priority nutrition-related health behaviors and the underlying behavioral reasons.

In addition, the research found that men often control household finances and decisions. Key influencers are fathers, grandmothers, midwives, community health volunteers, peers, and community leaders and religious leaders. Posyandu workers and antenatal care providers did not provide nutrition counseling on a consistent basis. Preferred media or sources of nutrition information were as follows, in order of preference: counseling; television; Posyandu; health workers; consultations; Internet and radio (IMA World Health, 2018).

MCA Indonesia also conducted a baseline survey in South Sumatera, West Kalimantan, and Central Kalimantan. Initial key findings included (IMA World Health, 2018):

• Low maternal breastfeeding knowledge and low exclusive breastfeeding • Less than 10 percent of those surveyed attended pregnant women classes • Stunting rates increased as children got older • Over half of pregnant mothers and children 6-35 months are anemic • Sanitation is very poor; less than 2 percent of villages are open defecation free


Table 12. Key findings of formative research conducted by MCA Indonesia to inform the NNCC

Health behavior and current practice Behavioral/environmental determinant Stunting. Stunting is not currently seen as a public health problem among mothers, as well as healthcare workers and non-healthcare stakeholders

• Some link stunting with nutrition intake or types of food, family economic condition, purchasing power, and mothers’ knowledge.

Maternal nutrition. Prenatal nutrition is poor, with reduced intake of animal protein. Reduced eating is common, as are food taboos. Only 64% of women received iron tablets and only 55% of these completed the recommended 90 tablets.

• Lack of awareness of antenatal nutrition importance by multiple members of the household.

• Pregnancy-related nausea. • Perpetuation of food myths by grandmothers. • Poor counseling on iron pills during ANC visits • Side effects (nausea, bad taste, bad smell) and social

misconceptions related to the use of iron pills. Early and exclusive breastfeeding. Almost all babies are breastfed. Almost half practiced exclusive breastfeeding to 6 months and almost 60% used infant formula. Other foods are commonly introduced before six months.

• Poor counseling during ANC visits • Insufficient training of birth attendants • Perception that breastmilk is nutritionally insufficient

and that supplementary food is needed. • Mothers have to go back to work. • Infant formula is believed to be equally good. • There is a widespread belief that honey is good for the

baby. Complementary feeding. Less than half of children under 2 eat twice a day or less. Half of mothers reported feeding only on demand. Most mothers fed only two food groups, grains (typically rice) and vegetables. Animal protein was rare

• Caregiver’s knowledge and competence regarding complementary food is inadequate.

• Child-driven feeding practices. • Mothers are also reluctant to force feed to avoid

crying. • Poor feeding practices was more prevalent among

those mothers who lacked family support (particularly from husbands) and those who carry a greater share of domestic work.

Sanitation and Hygiene. Only 1 out of 3 mothers reported using latrines. Open defecation is socially condoned, especially for those who live along rivers. Soap is only available in 34.6% of households; only 23.6% of homes had running water. Surveys found good knowledge of hand washing with soap, but poor practice.

• Handwashing facilities with running water and soap are limited and are often located outside the home.

• People lacked knowledge about handwashing at critical times.

Source: IMA World Health. Final Report: NNCC Model and Lessons Learned (2015-2018)

Research Limitations The study design is not well-described. For instance, total sample size was not reported, nor sample size by data collection method and population. In addition, it is not known if data saturation (i.e. the point at which no new information or themes are observed in the data collected) occurred during data collection.

National Nutrition Communication Campaign (NNCC) Overview The above formative research was used to inform the NNCC campaign and was implemented by the Indonesian MoH, with support from MCA Indonesia and IMA World Health.

As a result of the findings from the formative and baseline research, the NNCC used four major strategies to promote awareness of stunting and address child feeding practices, sanitation, and hygiene:


1. Encourage families, communities, and policy makers to prioritize stunting reduction and improved nutrition using mass media and digital media platforms.

2. Partner with health workers, cadres and communities to support families to improve child feeding and hygiene.

3. Empower families to make choices that improve their quality of life. 4. Engage stakeholders to create a positive climate for stunting reduction.

Target audiences for the campaign included adolescent girls, pregnant girls, mothers with children under-two, spouses, family members, community and informal leaders, health workers, policymakers, and other stakeholders. The campaign employed two approaches to deliver the messages. The first approach was a mass media campaign with national coverage which was implemented to reinforce and popularize key nutrition messages. These messages were pre-tested with target audiences through focus group discussions in South Sumatera, West Kalimantan, and Central Kalimantan. The second approach consisted of interpersonal communication (IPC), advocacy, and community-based communication activities and events, which will be implemented through Posyandu, mothers’ classes, and community gatherings. (IMA World Health, 2018)

Output and process indicators were collected throughout the campaign using a variety of quantitative and qualitative methods to collect data month, bi-monthly, quarterly, and annually from priority districts. Following the end of the campaign in 2018, this data will be analyzed and reported on to evaluate the campaign’s success (IMA World Health, 2018).

Public Service Announcement Understanding Television public service announcements (PSAs) developed by MCA Indonesia targeted primary caregivers of young children aged 6 – 23 months emphasized the following predetermined messages: 1) tips for active feeding, 2) appropriate complementary feeding: give three meals and two healthy snacks starting from 6 months old, 3) eat varied food or menu that consist of carbohydrate, protein, mineral and vitamin source, 4) handwashing with soap, 5) healthy children who are not stunted have good cognitive ability, and 6) go to Posyandu to get appropriate health and nutrition advise (MCA Indonesia, 2016). Research on the understanding and penetration of this ad by MCA Indonesia indicated that 65 percent of those respondents who had seen at least one of the ads (50 percent of n=330) mentioned the active feeding PSA. However, understanding of the key messages was mixed, with 71 percent of respondents understanding the messages about tips for active feeding, compared to a 7 percent understanding of the need to go to Posyandus for nutrition counseling. Approximately one-third of respondents understood the need for appropriate CF in terms of frequency and age, as well as understanding that healthy children are not stunted and have good cognitive abilities. Less than 20 percent of respondents understood how to improve children nutrition and good feeding patterns, the importance of dietary diversity, and handwashing with soap. A figure detailing respondents’ understanding of these messages can be found below (Figure 9) (MCA Indonesia, 2016).


Figure 9. MCA Indonesia NNCC Campaign "Active Feeding" PSA Understanding

Source: MCA Indonesia Media Monitoring Report, 2017

Three major messages recalled from this PSA included: tips for active feeding (71 percent), appropriate complementary feeding in terms of frequency and variation (31 percent), stunting prevention has impact on good cognitive ability (31 percent) (MCA Indonesia (2016). Eighty-seven percent of respondents indicated that the PSA was relevant to their needs as mothers and caregivers.

MCA Indonesia also included sanitation as a priority area after doing formative research and baseline interviews in 10 provinces. The baseline survey indicated that Sanitation is very poor, especially in Central and East Kalimantan, where many people live along rivers. Less than 2 percent of villages are open–defecation free. Only 3 of 379 control villages and 8 of 380 treatment villages are open-defecation free. Mothers dispose of children’s feces openly, as it is not considered harmful. Based on this data, a PSA was developed with the following predetermined messages: 1) no open defecation, 2) use latrine with septic tank, 3) making latrine is not expensive, 4) washing hand with soap, 5) healthy child, not stunted and have good cognitive ability. Research on the penetration and understanding of the sanitation PSA revealed that of those who recalled at least one PSA (50 percent), 65 percent reported seeing the sanitation PSA, with the following four messages recalled: maintain clean and healthy living environments (49 percent), no open defecation (47 percent), health latrines (46 percent), and hand washing with soap (36 percent). Understanding of the predetermined messages was mixed, with less than 50 percent of respondents having reported an understanding of the predetermined messages, as indicated in 10 below (MCA Indonesia, 2016).

71%

31%

31%

18%

16%

14%

7%

1%

1%

0% 20% 40% 60% 80%

Tips for active feeding

Appropriate complementary feeding in term of…

Healthy child, not stunted and have good cognitive…

How to improve child nutrition and good feeding…

Food variation: carbohydrate, protein, mineral,…

Hand washing with soap

Come to Posyandu

Hand washing

Others

Respondent Understanding on “Active Feeding” PSA messages (n=330)


Figure 10. MCA Indonesia NNCC Campaign "Sanitation" PSA Understanding

Source: MCA Indonesia Media Monitoring Report, 2017

The NNCC is still ongoing until 2018, where monitoring and evaluation data will be analyzed and subsequent reporting done. MCA Indonesia noted many lessons learned, summarized below.

Table 13. Summary of lessons learned from MCA Indonesia NNCC

Lesson Area Key Lessons Learned

Mass media

• Broadcast intensity is key • Deliver concise, focused messaging • Include humorous, fun messaging • Mass media featuring recognized leaders has impact • Strategic placement increases viewership • Radio can serve to amplify information delivered through IPC and group

communications • Formative research is essential

Digital media

• Social media is appropriate and effective • Ensure adequate time and budget for digital media development • Avoid “text heavy” formats • Increase traffic via Facebook ads

Print media • Build partnerships with journalists (print and electronic) • Ensure adequate budget for print media

Partnering with health workers, cadres, and communities

• Ensure communication skills development for cadres and health workers • Improve the Posyandu experience through interactive activities for

parents and children • Support outreach • Capitalize on existing health programs • Link campaign activities with national events • Build broad partnerships, including mosques and churches • Collaborate with bidan lewu (traditional birth attendants) • Ensure accessibility to remote locations

Empowering families to improve quality of life

• Promote male involvement

Engaging multi-stakeholders to create a supportive policy environment

• Advocacy targeting political leaders is an essential step • Establish a synergy to amplify campaign impact • Target faith-based organizations in advocacy interventions • Collaborate existing networks for social mobilization • Coordinate with field-level implementers • Build broad partnerships and coalitions

Source: IMA World Health. Final Report: NNCC Model and Lessons Learned (2015-2018)

49%

47%

46%

36%

8%

7%

4%

0% 15% 30% 45% 60%

Maintain clean and healthy environment

No open defecation

Healthy latrine

Hand washing with soap

Make latrine is not expensive

Healthy child and have good cognitive ability

About diarrhoea

Respondent’s Understanding on “Sanitation” PSA messages (n=330)


While the campaign provided many insights into how to successfully enact nutrition-related behavior change using multiple, integrated modalities, some limitations exist. Baseline data, used to inform the NNCC and serve as an indicator of its success, only covered three provinces, while the campaign was nationally implemented. This makes the sample less representative of the target audience.

GAIN Formative Research – The “Baduta Project” (2013)

Objective and Methods GAIN and the Indonesian MoH sought to implement a project whose aims were to reduce maternal and child malnutrition, particularly stunting and iron-deficient anemia. The project focused on nutrition-specific and nutrition-sensitive interventions, focusing on (1) improving infant feeding practices, as well as infant and maternal care practices (including hygiene); (2) strengthening health services at the community level, particularly nutrition interventions and (3) improving the availability and accessibility of high-quality nutritious products for young children and mothers. GAIN conducted formative research to specifically understand the motivations and barriers for mothers’ choice in relation with infant feeding (GAIN, 2013).

The behavior change intervention resulted from the formative research in East Java aims to improve the nutritional intake of children between ages 0 and 24 months old from low income families, by 1) delaying and reducing the use of industrial milks, and by doing so, support mothers to exclusively breastfeed till 6 months and continue breastfeeding until 24 months of age, and 2) improving appropriate complementary feeding practices and filling in the nutrient gap by increasing appropriate use of complementary foods (GAIN, 2013).

Formative research was conducted in May 2013 in Sidoarjo, East Java. This area was chosen by researchers because East Java was among the top three provinces with nutrition-related deficits, according to the 2007 RISKESDAS. Research was conducted in low-income, peri-urban households among parents of children under two years of age. Sub-samples included parents with a child diagnosed as under-nourished as well as pregnant women. The final sample included families living in five villages, in three sub-districts of Sidoarjo. Data collection methods included video recordings, in-depth interviews, focus group discussions, a nutrition-related event, key informant interviews, and neighborhood, shop, and facility visits (GAIN, 2013).

Results Mothers almost universally know and believe that breastmilk is the best food for babies, there is a confidence gap in their own ability to produce the right quality and quantity of breastmilk. Most mothers are unaware that decreased breastmilk production is linked to consumption of formula by their child. Most parents and midwives share similar views that sufor (infant formula) and regard it as a universal supplement that is not in opposition to breastmilk. The perception of the majority is that the older the baby, the less priority to breastfeed the baby. Breastfeeding no longer becomes a priority after the baby turns 6 months. It is only for comfort and sleep time (GAIN, 2013).

Mothers had relatively good knowledge on how to properly feed their children, though there is some lack of understanding on spacing, quantities and interference between formula consumption and breastmilk production or between snacking before meals and meal consumption. Snacking is primarily child-driven and is used to comfort cranky or restless children. Mothers do not typically let children go hungry between meals. Snacks are sometimes used as a substitution for meals when children are reluctant or refuse to eat meals (GAIN, 2013).

Mothers know how important it is to give different types of foods such as fruit, vegetables, and meat, but there is a lack of understanding of a child’s need for nutrient-dense foods. Babies are


typically fed during family meal times. Semi-solid (fortified) commercial products are useful as a short-term bridge before the baby is given home-cooked family foods, which is very heavy on rice (carbohydrates) and insufficient nutrient-dense (GAIN, 2013).

Child feeding appears to depend heavily on external factors such as mother’s (lack of) confidence, socioeconomic status, family roles (particularly parent-child), household structure, and advice through primary health care services (GAIN, 2013).

Limitations While GAIN used multiple qualitative methods to understand the behaviors and knowledge driving breastfeeding and complementary feeding, numerous study limitations exist. It is difficult to understand how these findings generalize to a national level as the study was only conducted in one region of East Java, making it unknown what is practiced in other parts of Indonesia. The small sample size (n=54) also makes these findings less generalizable. In addition, researchers did not interview maternal influencers, including spouses, family members, and healthcare providers, so it is unknown the extent to which they influence a mother’s child feeding practices and the extent to which other family members participate in child feeding.

4. Conclusions

Significant research has been conducted in varying parts of Indonesia that contribute to the understanding of MIYCN practices, attitudes, and interventions. Indonesia has significantly improved all MCH, IYCF, and WASH practices over the course of the last decade. However, much work needs to be done to meet the needs of a quickly developing country. The Indonesian government and the MoH have set ambitious targets for many of these indicators, with universal health coverage being a main goal to serve as a facilitator for the improvement of women and children around the country. From that, cultural and social practices are strong drivers of behavior. This includes the influence from significant figures such as family members and health personnel. These behaviors have profound consequences on the nutrition of infants and young children, and there is much that can be done to shift many of these norms in favor of culturally-responsive health behaviors.

Research related to specific areas, such as feeding practices surrounding illness and early childhood development for children under two and early child development is still lacking, with much to learn about how the behavioral factors related to these topics influence nutrition. Many knowledge and programmatic gaps remain, especially as it relates to SBCC, with formative research needed to adequately understand what programming is sustainable and impactful in areas with the highest needs. With new demographic data set to be released next year, it is important to understand the motivators and barriers to the disparities seen in this data so they can be effectively capitalized or removed. Therefore, there is a call for formative research to understand specific social norms to ensure future messaging is evidence-based. In addition, the evidence synthesized above points to no one intervention or determinant that completely addresses MIYCN in Indonesia. To address stunting in the longer term, interventions need to address these variables and other underlying causes of undernutrition, such as poverty, infrastructure, and unhealthy environment.


5. Appendices

Appendix 1. Framework for actions to achieve optimum fetal and child nutrition and development

Source: Black, Robert E et al. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet, Vol. 382, Issue 9890, p. 428.


Appendix 2. Under-five stunting prevalence by province for Indonesia in 2007, 2010 and 2013

Source: RISKESDAS, 2013


Appendix 3. Percentage of men and women that justify any reason for hitting of beating one’s wife, by background characteristics, Indonesia 2012

Background Characteristic Women Men

Age 15-19 44.9 48.4 20-24 39.3 22.9 25-29 36.1 22.6 30-34 32.8 18.4 35-39 30.3 19.5 40-44 29.4 16.4 45-49 26.6 13.5

Employment (last 12 months) Not employed 36.3 6.2 Employed for cash 31.9 17.2 Employed not for cash 37.8 20.0

Marital Status Never married 38.5 N/D Married or living together 33.5 N/D Divorced/separated/widowed 30.9 N/D

Residence Urban 29.8 14.7 Rural 39.5 20.0

Education No education 26.6 17.2 Some primary 33.3 19.4 Completed primary 36.5 18.0 Some secondary 40.1 19.1 Completed secondary 32.1 16.5 More than secondary 25.5 11.8

Wealth Quintile Lowest 42.2 22.8 Second 38.2 19.9 Middle 35.4 18.2 Fourth 31.3 14.4 Highest 27.5 12.1

Overall 34.5 17.2

Source: Statistics Indonesia (Badan Pusat Statistik-BPS) (2012). "Indonesia Demographic and Health Survey 2012 ".


Appendix 4. Percent distribution of married women age 15-49 by contraceptive method currently used, according to background characteristics, Indonesia 2017.

Any modern method

Female sterilization

Male sterilization

IUD Pill Injectables Implants Condom

Age 15-19 43.8 0.0 0.0 0.7 7.3 33.6 2.3 0.0 20-24 55.4 0.0 0.0 3.0 8.5 39.1 3.6 0.9 25-29 55.7 0.2 0.0 4.6 9.2 33.8 5.2 2.5 30-34 61.0 1.6 0.1 5.2 11.9 34.0 5.2 3.0 35-39 63.9 4.6 0.1 5.6 14.9 30.0 5.7 3.0 40-44 60.8 7.3 0.2 5.3 14.6 24.6 5.5 3.2 45-49 44.6 7.1 0.5 3.9 11.7 16.3 2.8 2.1

Residence Urban 55.0 4.8 0.2 6.7 11.9 24.8 2.8 3.7 Rural 59.2 2.8 0.2 2.9 12.4 33.0 6.6 1.4

Education No education 34.5 2.6 0.1 0.9 8.9 18.2 3.3 0.2

Some primary 56.9 3.8 0.4 1.7 13.4 30.5 6.5 0.7

Completed primary 63.7 3.4 0.3 2.9 15.7 35.1 5.7 0.7

Some secondary 61.7 3.0 0.2 3.7 12.7 34.6 5.3 2.1

Completed secondary and beyond

51.1 4.5 0.1 7.5 9.3 21.5 3.4 4.6

Number of living children

0 4.3 0.2 0.0 0.0 2.0 2.0 0.0 0.1 1-2 60.6 1.6 0.1 5.2 13.1 33.1 4.6 2.8 3-4 65.9 8.8 0.3 5.4 13.5 29.0 6.0 2.8 5+ 48.6 11.2 0.7 2.3 8.3 17.2 7.1 1.7

TOTAL 57.2 3.8 0.2 4.7 12.1 29.0 4.7 2.5 Source: 2017 IDHS Preliminary Report


Appendix 5. Percentage of adolescent women age 15-19 who have begun childbearing, by province, Indonesia 2012

Province Women age 15-19 who have begun childbearing

Indonesia 9.5 Sumatera

Aceh 5.2 North Sumatera 4.7 West Sumatera 3.3 Riau 5.8 Jambi 16.4 South Sumatera 11.9 Bengkulu 8.8 Lampung 11.9 Bangka Belitung Islands 11.6 Riau Islands 4.8

Java DKI Jakarta 4.1 West Java 11.2 Central Java 5.7 DI Yogyakarta 6.1 East Java 10.1 Banten 7.5

Bali and Nusa Tenggara Bali 8.9 West Nusa Tenggara 12.3 East Nusa Tenggara 6.3

Kalimantan West Kalimantan 22.9 Central Kalimantan 20.5 South Kalimantan 16.4 East Kalimantan 13.0 North Kalimantan N/D

Sulawesi North Sulawesi 15.0 Central Sulawesi 19.7 South Sulawesi 10.6 Southeast Sulawesi 15.8 Gorontalo 13.6 West Sulawesi 17.1

Maluku and Papua Maluku 7.9 North Maluku 11.8 West Papua 17.3 Papua 14.3

*Child bearing is defined by having had a live birth or are currently pregnant with their first child Source: Statistics Indonesia (Badan Pusat Statistik-BPS) (2012). "Indonesia Demographic and Health Survey 2012 ".


Appendix 6. Provincial coverage of key maternal indicators, Indonesia 2015

Province

Pregnant Women Delivering Women Postpartum Women

First ANC visit attendance (%)

Fourth ANC visit attendance (%)

Antenatal iron supplementation, 90 tablets (%)

Health personnel-assisted deliveries, total (%)

Health personnel-assisted deliveries in healthcare facilities (%)

Health personnel-assisted deliveries in non-healthcare facilities (%)

Postpartum visits (%)

First natal visit (%)

Received vitamin A dose (%), 2012

Indonesia 95.75 87.48 85.17 88.55 79.72 8.83 87.06 83.67 48.1

Sumatera Aceh 83.21 75.67 73.19 78.00 72.98 5.02 73.40 83.74 40.6 North Sumatera 82.44 75.50 74.42 76.17 63.85 12.32 86.96 76.36 33.0

West Sumatera 88.18 79.19 79.16 81.87 78.55 3.31 74.11 76.29 43.2

Riau 91.91 85.67 83.21 84.43 57.12 27.31 62.94 79.32 35.4 Jambi 99.43 93.92 90.29 93.49 56.27 37.21 92.51 95.77 44.0 South Sumatera 97.66 93.45 85.31 90.16 72.68 17.48 85.77 69.27 46.0

Bengkulu 95.92 89.45 87.22 88.43 58.21 30.22 82.23 93.02 43.5 Lampung 95.91 88.62 82.92 89.27 82.89 6.38 90.24 94.42 47.4 Bangka Belitung Islands

98.36 92.35 90.21 94.10 84.07 10.03 93.61 98.93 52.5

Riau Islands 104.73 98.19 79.07 99.80 95.35 4.45 112.89 84.40 37.9

Java DKI Jakarta 99.75 95.22 97.12 96.16 87.27 8.90 93.58 98.71 48.5 West Java 104.27 97.97 95.51 95.95 89.94 6.00 97.23 93.31 43.3 Central Java 98.58 93.05 92.13 98.09 94.96 3.12 92.47 100.06 47.4

DI Yogyakarta 100.00 92.59 89.01 99.95 99.81 0.14 98.49 80.71 52.5

East Java 98.75 91.24 89.73 95.81 94.76 1.05 95.72 100.41 60.7 Banten 96.06 85.67 76.00 76.71 75.87 0.85 86.35 90.09 52.7

Bali and Nusa Tenggara Bali 98.70 93.32 95.07 97.78 73.67 24.11 97.19 100.32 55.5 West Nusa Tenggara 100.00 92.07 92.70 89.79 88.54 1.25 74.79 95.82 50.2

East Nusa Tenggara 84.95 61.63 74.44 69.97 65.95 4.02 69.30 41.92 54.9

Kalimantan West Kalimantan 94.22 84.68 80.43 82.24 56.04 26.20 76.19 75.03 34.8

Central Kalimantan 93.32 85.75 71.21 83.20 40.20 43.00 79.47 81.00 39.9

South Kalimantan 99.40 81.02 87.80 89.08 65.57 23.50 85.45 83.05 46.7

East Kalimantan 99.62 87.05 75.14 91.26 76.65 14.62 79.74 90.44 44.3

North Kalimantan 93.23 81.14 87.96 85.87 73.48 12.39 81.89 78.92 n/d

Sulawesi North Sulawesi 96.23 86.11 79.56 85.94 79.88 6.06 84.20 75.45 47.5


Central Sulawesi 83.82 71.07 63.42 72.51 56.16 16.35 70.82 51.90 44.1

South Sulawesi 99.48 91.72 87.52 90.97 86.91 4.07 91.61 10.51 43.2

Southeast Sulawesi 94.59 80.89 73.90 86.29 52.30 33.99 84.81 77.22 45.8

Gorontalo 100.46 88.08 85.04 92.34 90.62 1.71 81.22 71.46 50.2 West Sulawesi 94.25 76.04 72.92 85.56 76.53 9.03 70.46 73.56 31.3

Maluku and Papua Maluku 55.93 43.88 47.16 46.90 30.08 16.82 43.39 44.69 40.1 North Maluku 86.60 72.03 69.82 69.64 53.05 16.59 64.10 51.02 50.1

West Papua 58.70 30.40 47.30 41.90 31.87 10.02 28.50 20.40 45.7

Papua 56.02 24.45 24.36 34.14 26.34 7.80 28.34 14.95 29.7

Those cells in red indicate coverage did not meet 2015 Strategic Plan targets. Source: Indonesia Health Profile, 2015


Appendix 7. Early childhood mortality rates per 1,000 live births by province, Indonesia 2012

Province Neonatal mortality (0-27 days)

Post-neonatal mortality (28-364 days) Under-five mortality

Indonesia 20 14 43 Sumatera

Aceh 28 18 52 North Sumatera 26 14 54 West Sumatera 17 10 34 Riau 15 9 28 Jambi 16 18 36 South Sumatera 20 8 37 Bengkulu 21 8 35 Lampung 20 10 38 Bangka Belitung Islands 20 7 32 Riau Islands 21 13 42

Java DKI Jakarta 15 7 31 West Java 17 13 38 Central Java 22 10 38 DI Yogyakarta 18 7 30 East Java 14 15 34 Banten 23 9 38 Bali and Nusa Tenggara Bali 18 11 33 West Nusa Tenggara 33 24 75 East Nusa Tenggara 26 19 58

Kalimantan West Kalimantan 18 13 37 Central Kalimantan 25 24 56 South Kalimantan 30 14 57 East Kalimantan 12 9 31 North Kalimantan n/d n/d n/d

Sulawesi North Sulawesi 23 9 37 Central Sulawesi 26 32 85 South Sulawesi 13 12 37 Southeast Sulawesi 25 20 55 Gorontalo 26 41 78 West Sulawesi 26 34 70

Maluku and Papua Maluku 24 12 60 North Maluku 37 24 85 West Papua 35 39 109 Papua 27 27 115

Source: Statistics Indonesia (Badan Pusat Statistik-BPS) (2012). "Indonesia Demographic and Health Survey 2012 ".


Background Characteristic

Total births with reported birthweight (%)

Births reported less than 2.5 kg (%)

Births reported as “very small” (%)

Births reported as “smaller than average” (%)

Mother’s age at birth <20 85.0 10.3 2.5 14.9 20-34 90.0 6.8 1.9 10.7 35-49 88.4 8.3 1.9 13.1

Birth order 1 92.3 7.6 1.9 12.1 2-3 90.6 6.8 1.8 11.0 4-5 81.3 8.6 2.8 10.7 6+ 66.3 7.9 2.3 12.1

Mother’s smoking status

Smokes cigarettes/tobacco 73.2 4.4 1.8 8.7

Does not smoke 89.6 7.4 1.9 11.5 Residence

Urban 96.2 6.2 1.7 10.7 Rural 82.5 8.6 2.2 12.2

Mother’s education No education 35.9 14.5 3.4 11.0 Some primary 73.2 13.2 4.5 15.1 Completed primary 85.0 9.7 2.1 13.7

Some secondary 91.0 6.2 1.7 9.9 Completed secondary 96.7 6.1 1.5 11.1

More than secondary 98.0 4.9 1.1 8.9

Wealth quintile Lowest 69.0 11.2 2.2 13.9 Second 89.8 7.2 2.1 11.8 Middle 93.6 7.8 2.3 12.1 Fourth 97.7 6.3 1.5 10.7 Highest 98.8 5.0 1.6 8.5

Total 89.3 7.3 1.9 11.5 Source: Statistics Indonesia (Badan Pusat Statistik-BPS) (2012). "Indonesia Demographic and Health Survey 2012 "

Appendix 8. Percentage of LBW and small size newborns, by mother's background characteristics, Indonesia 2012


Appendix 9. Coverage of 6 - 59-month-old children supplemented with Vitamin A capsules by province, Indonesia 2015 (Source: Indonesia Health Profile, 2015)

Province 6-11-month-old children (%)

12-59-month-old children (%)

6-59-month-old children (%)

Indonesia 75.4 84.9 83.5 Sumatera

Aceh 91.5 92.1 92.0 North Sumatera 16.4 77.4 53.2 West Sumatera 89.2 91.0 90.8 Riau 82.6 82.4 82.5 Jambi 94.0 90.2 90.7 South Sumatera 87.6 85.2 85,5 Bengkulu 93.1 91.8 92.0 Lampung 80.4 82.2 82.0 Bangka Belitung Islands 93.1 89.7 90.1

Riau Islands 82.7 76.0 76.7 Java

DKI Jakarta 70.9 55.3 56.9 West Java 98.7 82.7 84.5 Central Java 98.9 98.6 98.6 DI Yogyakarta 99.3 98.7 98.8 East Java 99.2 91.7 92.6 Banten 94.4 83.3 84.5 Bali and Nusa Tenggara

Bali 95.7 95.0 95.1 West Nusa Tenggara 98.2 96.6 96.8 East Nusa Tenggara 88.7 89.1 89.1

Kalimantan West Kalimantan 83.0 76.9 77.6 Central Kalimantan 75.5 77.0 76.8 South Kalimantan 93.1 84.5 85.4 East Kalimantan 84.2 64.1 66.0 North Kalimantan 70.5 69.8 69.9

Sulawesi North Sulawesi 88.2 89.3 89.1 Central Sulawesi 90.4 89.3 89.4 South Sulawesi 90.2 79.8 81.0 Southeast Sulawesi 89.0 82.1 83.0 Gorontalo 97.9 98.2 98.2 West Sulawesi 79.5 78.1 78.4

Maluku and Papua Maluku n/d n/d n/d North Maluku 77.4 82.9 82.1 West Papua n/d n/d n/d Papua n/d n/d n/d


Appendix 10. Coverage of Initial Breastfeeding Among Last Born Children within the Past Two Years Preceding Survey by Province, 2012*

Province % Ever Breastfed % who started breastfeeding within 1 hour of birth

% who started breastfeeding within 1 day of birth

Indonesia 95.8 49.3 66.3 Sumatera

Aceh 95.6 46.4 63.5 North Sumatera 94.2 17.1 38.9 West Sumatera 96.2 38.6 72.1 Riau 91.8 26.2 44.9 Jambi 96.5 35.7 53.5 South Sumatera 96.3 35.9 58.8 Bengkulu 95.0 39.8 61.4 Lampung 95.2 43.9 60.9 Bangka Belitung Islands 90.1 53.4 60.2 Riau Islands 92.2 51.5 70.7

Java DKI Jakarta 93.7 60.1 71.8 West Java 96.8 56.7 76.0 Central Java 96.8 54.9 74.1 DI Yogyakarta 95.8 55.1 75.2 East Java 96.9 52.2 66.7 Banten 95.5 49.5 62.7

Bali and Nusa Tenggara Bali 90.5 47.9 59.6 West Nusa Tenggara 98.7 73.7 85.3 East Nusa Tenggara 98.0 68.2 80.2

Kalimantan West Kalimantan 92.9 39.1 48.6 Central Kalimantan 95.8 42.5 48.2 South Kalimantan 95.3 46.8 59.8 East Kalimantan 94.5 46.9 62.0 North Kalimantan n/d n/d n/d

Sulawesi North Sulawesi 93.5 40.9 59.2 Sulawesi Tengah 97.1 38.9 58.3 South Sulawesi 95.3 56.9 67.2 Sulawesi Tenggara 94.2 43.2 55.4 Gorontalo 94.7 36.7 63.5 West Sulawesi 96.1 56.7 70.9

Maluku and Papua Maluku 89.2 35.1 60.2 North Maluku 94.5 47.6 62.4 West Papua 95.6 32.5 64.9 Papua 96.9 64.1 78.4

*Source: Statistics Indonesia (Badan Pusat Statistik-BPS) (2012). "Indonesia Demographic and Health Survey 2012 ".


Appendix 11. Coverage of Exclusive Breastfeeding of 0-6-Month-Old Infants by Province, 2015*

Province 0-6-Month-Old Infants

Exclusively Breastfed 0-6-Month-Old Infants Exclusively Breastfed

Indonesia 3,561,617 1,983,066 55.7 Sumatera

Aceh 95,491 55,715 58.3 North Sumatera 189,985 62,777 33.0 West Sumatera 69,676 52,269 75.0 Riau 93,243 63,488 68.1 Jambi 50,997 35,498 69.6 South Sumatera 135,874 81,868 60.3 Bengkulu 24,668 18,782 76.1 Lampung 163,215 89,550 54.9 Bangka Belitung Islands 19,609 11,340 57.8 Riau Islands 30,759 17,486 56.8

Java DKI Jakarta 54,965 36,907 67.1 West Java 877,626 309,665 35.3 Central Java 398,358 223,385 56.1 DI Yogyakarta 31,103 22,276 71.6 East Java 507,094 375,737 74.1 Banten 141,791 93,369 65.8 Bali and Nusa Tenggara

Bali 38,127 28,109 73.7 West Nusa Tenggara 92,550 80,412 86.9 East Nusa Tenggara 71,234 54,839 77.0

Kalimantan West Kalimantan 39,990 27,350 68.4 Central Kalimantan 21,164 8,078 38.2 South Kalimantan 65,391 40,176 61.4 East Kalimantan 51,322 25,431 49.6 North Kalimantan 6,925 3,890 56.2

Sulawesi North Sulawesi 36,702 9,657 26.3 Central Sulawesi 34,661 19,191 55.4 South Sulawesi 102,526 73,339 71.5 Southeast Sulawesi 33,195 17,972 54.1 Gorontalo 16,101 7,528 46.8 West Sulawesi 22,033 13,778 62.5

Maluku and Papua Maluku 21,611 8,578 39.7 North Maluku 11,663 7,505 64.3 West Papua 11,968 7,121 59.5 Papua n/d n/d n/d



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Documents

Maternal, Infant, and Young Child Nutrition and Nutrition ... · GAIN Global Alliance for Improved Nutrition . IDHS Indonesia Demographic Health Survey . IMA Interfaith Medical Assistance