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INTERNATIONAL CONFERENCE ON CSR AND COMBATING MALNUTRITION:
OBTAINING MILLENNIUM DEVELOPMENT GOALS (MDGs) IN INDONESIA
Grand Sahid Jaya Hotel, 13 – 14 December 2010
Session 1: Prevention & Intervention in Improving The National
Nutrition Status in Indonesia
Budi Iman Santoso, Sp. O.G., Head of Obstetrics & Gynecology,
Cipto Mangunkusumo Hospital
EFFORTS OF OBSTETRIC CARE
ON REDUCING MATERNAL MORTALITY
RATE TO ACHIEVE MDG TARGETS
IN INDONESIA
Dr. Budi Iman Santoso, SpOG(K)
DEPARTMENT OF OBSTETRIC-GYNECOLOGY
CIPTO MANGUNKUSUMO HOSPITAL –
FACULTY OF MEDICINE UNIVERSITY OF INDONESIA -
JAKARTA
OUTLINE
Introduction
Achievement of Reduced MMR
Comprehensive analysis
◦ Linear and Dynamic System
◦ Priority Strategy – 5W + 1 H
Role of Obstetric Care
SWOT Analysis
Conclusion
INTRODUCTION
Millenium Development Goals (MDGs)
September, 2000 – the Millenium Summit of
189 UN Nations, the Millenium Declaration
Indonesia:
◦ The National Long-term Development Plan
RPJPN (2005-2025)
◦ Mid-term: RPJMN 2005-2009 & 2010-2014
◦ Annual: RKP
INTRODUCTION… MDGs
Pro-growth, pro-jobs, pro-poor and pro-environment
8 targets:
5A. Reduce MMR by three-quarters
between 1990-2015
5B. Achieve universal access to
reproductive health
THE CURRENT STATUS OF MDG TARGETS
3 categories of MDG achievement
A. Have already been achieved: 1,3,6
B. Significant progress has been achieved: 1,
2, 3, 4, 8
C. Still requires great efforts to be
achieved:
1,5,6,7
REDUCED MATERNAL MORTALITY RATE
IN INDONESIA
1992: 425/100.000
2007: 228/100.000
RJMPN 2014: 118
MDG 2015: 102
Acceleration initiatives!
Global: MDG 5 slow progress
◦ Only China and Vietnam have been “on track”
◦ Separating MDG 5A and 5B (introduced 2007)
Indicators of Achievement: MDG 5
Mostly, still need special
attention
Indonesia: We are not alone
– similar results in Asia
Pacific region
COMPREHENSIVE ANALYSIS
LINEAR SYSTEM OF THINKING
DYNAMIC SYSTEM
PRIORITY STRATEGY – 5 W + 1 H
LINEAR SYSTEM :
Gender, Nutrition, Safe Abortion
Pre-Pregnancy, Pregnancy, Labor & Delivery,
Post-Partum
Gender Issues- Reproductive Health:
Woman’s Basic Human Rights
Safe mother – Safe child
Mother’s nutrition - neglected
Dear man,
Do you really care for your woman & children??
Family Planning – Safe Abortion,
Woman’s right
Woman’s right is not only in Education and Work
But most importantly is the right to decide what’s best for her
body
DYNAMIC SYSTEM :
4 sub-systems:
◦ Demography, social and culture (blue)
◦ Family Planning (yellow)
◦ Quality of labor assistance (red)
◦ Environment and sanitation (grey)
PRIORITY STRATEGY 5W
+1H WHAT – 4 Priority Strategies, 1 Vision:
“Making Pregnancy Safer”
◦ Quality of Effective Health Services
◦ Inter-program/sector/private partnership
◦ Family empowerment
◦ Public Mobilization
WHERE – Extreme extensive area in
Indonesia Map of Priority for Target
Area
PRIORITY STRATEGY 5W
+1H WHO –
◦ Target: mother and couples of reproductive
age
◦ Executor: Health care professionals
Mutual responsibilities: government,
private & community
Need a Consultant Manager?
Role of general practitioner in assisting
labor (in service & pre-service)
PRIORITY STRATEGY 5W
+1H WHEN – tight deadline 2015
◦ When is the best time for monitoring & evaluation
◦ Improvement on indicator – Official / Alternative
indicator
WHY – clearly stated in linear & dynamic
system
HOW – Start the Effective Strategy ASAP
◦ Guidelines
◦ Meetings & panel discussion
Official or Alternative indicators?Asian-Pacific Resource &Research for Woman (ARROW)
THE ROLE OF OBSTETRIC CARE
Most maternal death is due to obstetric
complication and emergency
Risk of maternal death – extremely high:
◦ 100 x on First day after labor
◦ 30 x on Second day postpartum
◦ 14.8% - 1 week before labor
◦ 43.5% during labor
◦ 23.7% in 1 week after labor
Obstetric care has important role on Strategy 1
(Access and Quality Health Services)
Obstetric and neonatal emergency care
Preventive and promotive care:
◦ Pre-pregnancy (Family Planning, Pre-marital
counseling, Improved Nutrition, Immunization)
◦ During pregnancy (ANC, BPCR, Fe, Calcium (PE/E),
Immunization)
◦ During Labor (Labor assistance in Health Care
Facility, Safe and Clean Labor, CTG, Biophysical
profile, Partograf, MAK III, Initial breast feeding)
ROLE OF OBSTETRIC CARE
JNPK (Jaringan Nasional Pelatihan Klinik) & MOH
Directorate General of Medical Services have conducted
training on Comprehensive Emergency Obstetrics and
Neonatal Care (CEONC) at Tangerang Hospital (2008-
2009)
Training Results
20 hospital staff (3 obs-gyn, 2
pediatricians, 9 midwives, 6 nurses) are
certified in CEONC
4 Health Care units are certified in
BEONC
40 midwives are certified in LSS
Training results
Midterm Maternal Death reduced from 32/2998 to
12/3503 live-birth
Annual Maternal Death reduced from 52/5002 (2008)
to 29/7018 live-birth (2009).
Reduced Annual Mortality*
Mortality 2008 2009
Maternal
per 100,000 live-births800 300
Perinatal
per 1000 live-births30 16
Effective Obstetric Care
Cause of death Effective care % reduction
Bleeding AMTSL,Obstetric care,
transfusion
40%
Infection Preventing infection and
uses of antibiotics
13%
Eclampsia Magnesium Sulfate & anti
hypertension agents
7%
Delayed labor Partograf, Operator
competence
10%
ROLE OF OBSTETRIC CARE
Health care professionals have less role in
Strategy 2 (Inter-Program & Sector Partnership)
Rigid bureaucracy & regulation
Turniani L, et al: Strategic policy has supported
the program of reducing MMR
Sugeng et al: not all sectors have realized the
importance of program to reduce MMR
Program supported by local government policy
Province Supported Program
East Java APN, PONEK, AMP, PONED,
CAPACITY BUILD
South Kalimantan GSI, AMP, Bidan Siaga, MPS
North Sulawesi GSI, SPM, AMP
ROLE OF OBSTETRIC CARE
Least role in Strategy 3 (Family
Empowerment)
In Strategy 4 (Public Mobilization) it
depends on government initiatives to
involve the health care professionals
COULD WE ACHIEVE MDG 5 BY 2015??
SWOT analysis ON MDG 5 - 102/100,000 livebirth on 2015
STRENGTH
Fine human resource
Good strategy program
High commitment by the government,
private sectors (CSR)
Overseas fund: USAID for CEONC
Many programs have been conducted
Positive reduction on MMR, needs
acceleration
Weakness –
Different vision, not well-coordinated
Less concern on priority
Less awareness on woman’s right in
reproductive health
Geographical obstacles
Tight deadline
Problems in training of labor assistance
Opportunity –
Support by developed countries on MDG
program
Threat –
No concern on existing program
Egoism – fond of new program rather than
integrating with the existing program
CONCLUSION
Positive reduction in MMR needs acceleration
Issues on discussion:
◦ Gender equality / woman’s right: family planning, nutrition, safe
abortion
◦ Alternative indicators
◦ Effective Strategy
◦ Consultant manager
◦ Using technology : www. kesehatan-ibuanak.net Launching: 30
Nov 2010
◦ Training of labor assitance (in service dan pre-service)
◦ Fund rising
GREATEST THREAT:
WE DON’T CARE
I don’t care
REDUCING MMR
= Treating Wound Healing
At beginning… Everything looks terrible….
But … We Care !!(On courtesy of: Kompyang Rata, I Gusti Agung)
First month… After exhausting efforts of daily care..
Nearly loss of hope
But.. We do care!!!
Third month…. On Progress..
For the patient, it is still troublesome
But.. We still and do care !!
Fourth month… and there is a smile
120 x we’ve tried to be still and do care..
When it seems nothing…
Actually, there is everything…
Every dark cloud has a silver lining
Is it a road to DIE or to SMILE – We decide..