Nutrition, Health Status, Programs and Policy for Pregnant and Lactating Women in Indonesia

(1)

Nutrition, Health Status,

Programs and Policy for

Pregnant and Lactating Women

in Indonesia

Trihono

Senior Health Advisor Jakarta, 12 August 2014

(2)

Outline of Presentation

1. Maternal Mortality Ratio (MMR)

2. Coverage of maternal health services 3. Quality of maternal health services

4. Health & nutrition status of pregnant women

5. Policy & programs 6. Conclusion

(3)

Maternal Mortality Ratio

in Indonesia

(4)

(5)

MMR 1994 - 2012

390 334 307 228 359 0 100 200 300 400 500 1989-1994 1993-1997 1998-2002 2003-2007 2008-2012 MM R/100.000 LH Reference Period Source: IDHS 1994 - 2012

(6)

(7)

Follow up study on maternal death

(Population Census 2010)

• Pregnancy related death data was

collected during Population Census 2010

• More than 8,000 cases identified, 50%

(>4,000 cases) were revisited for verbal autopsy in 2011

• Analysis for identifying cause of death was

(8)

Cause of Maternal Mortality (Population Census 2010) Kode ICD 10, WHO Underlying cause of maternal death Region Indonesia Sumatera Jawa-Bali Kalimantan Sulawesi IBT

O00-O08 Pregnancy with abortive outcome

3.7 4.2 2.7 5.6 4.2 4.1

O10-O16 Oedema, proteinuria, and hypertensive disorder (HDK)

33.3 33.1 34.9 32.6 25.8 32.4

O44-O46 Placenta previa, premature separation of placenta and Antepartum haemorrhage

4.4 2.7 4.3 2.3 3.6 3.3

O30-O43, O47-O48

Other maternal care related to fetus and amniotic cavity and possible delivery

problems

3.0 1.7 0.0 0.8 0.1 1.6

O64-O66 Obstructed Labour 0.5 1.1 0.0 0.6 1.0 0.8

O72 Postpartum haemorrhage (PPP) 16.4 16.8 28.1 26.3 29.8 20.3 O20-O29, O60-O63, O67-O71, O73-O75, O81-O84 Other complications of pregnancy and delivery

11.1 6.0 2.9 7.9 5.9 7.2

O85-O99 Complication predominantly related puerperium and other conditions

27.6 34.3 27.1 23.9 29.7 30.2

Total 100.0 100.0 100.0 100.0 100.0 1000

32.4

(9)

Period of Maternal Death

Period N (%) Pregnant < 20 weeks 543 7.2 Pregnant > 20 weeks 1,372 18.2 Labor 974 12.9 Post partum 4,634 61.6 Total 7,523 100.0

(10)

Place of Maternal Death

42% 29% 16% 13% Government Hospital Home Private Hospital Others

(11)

Coverage of

(12)

Coverage of ANC, 1991 - 2012

0.0 20.0 40.0 60.0 80.0 100.0 1991 1994 1997 2002 2007 2012 55.1 63.1 70.4 81.0 81.5 87.8 K u n ju n g an A N C (% ) Reference period 4+ 2-3 1 0 Source: IDHS 1991 - 2012

(13)

Coverage of ANC-4 by Provinces, 2010 - 2013 61.4 70.0 0.0 20.0 40.0 60.0 80.0 100.0 M aluk u Papu a Paba r M alut Sulba r Sult eng Kalt eng Sult ra Gor ont al o N T T Suls el Kalba r Sum s el Sumut Jam bi Sulut _Kals el Ac eh Beng k ulu Sum bar R iau Kalt im Bant en IN D ON ESI A Bab e l N T B J abar _Jat im Lam pung Kep. R iau _DKI J at en g Bali DIY 2010 2013 Source: Riskesdas 2010 - 2013

(14)

Coverage of SBA: 2010 - 2013

79.0 86.9 0.0 20.0 40.0 60.0 80.0 100.0 Papu a Maluku M alut Sulba r N T T Paba r Kalt eng Sult eng Kalba r Sult ra Suls el Sulut _Jabar Bant en Kals el R iau IN D ON ESI A J am bi Sum s el Lam pung Kalt im Babe l Ac eh Gor ontal o N T B Sum bar Sum ut J atim Beng k ulu Kep. R iau Jate n g D KI Bali DIY 2010 2013 Source: Riskesdas 2010 - 2013

(15)

Coverage of PNC: 2010 - 2013

46.8 81.7 0.0 20.0 40.0 60.0 80.0 100.0 M aluk u Papu a Paba r N T T M alut Sulba r Kalba r Kalt eng Sult eng J abar Kep .Riau Lam pung Sum s el Sult ra Bant en Sulut _Sulsel IN D ON ESI A Babe l Sum bar Kalsel R iau Kalt im Sum ut Ac eh J am bi J at im N T B Gor ont al o J at en g D KI Bali Beng k ulu _DIY 2010 2013 Source: Riskesdas 2010 - 2013

(16)

Paradoxical condition

• Coverage of maternal health services is

increasing, but Maternal Mortality Ratio is not decreasing.

• Caused by:

1. Poor quality of maternal health services 2. Health & nutrition status of pregnant

women

(17)

Quality of

(18)

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 B ALI D I YOGY AKARTA JAM B I D KI JAKA RTA N USA TE N GGAR A TIM UR JAWAT EN GAH JA WA TI M UR B AN TE N N USA TE N GGAR A B A R AT JAWABAR AT RI A U SU M AT ER A SELAT AN SUM AT ERAB ARAT KALIM A N TA N B ARAT LAM PUN G KALIM A N TA N TIM UR GO R ON TA LO SULAWES I T EN GAH SULAWES I S ELAT AN SUM AT ERAUTARA PA P UA KEP . R IAU ACEH KALIM A N TA N TE N GAH SULAWES I UT A R A KALIM A N TA N SEL AT AN B EN GKU LU KEP . B AN GKA B ELIT UNG SU LAWESI T EN GG AR A SULAWES I BAR AT M A LU KU M A LU KUUTARA PA P UAB ARAT IN D O N ESIA 21.0

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

(19)

10.56 10.58 10.71 13.44 13.61 13.73 13.87 14.04 14.29 14.35 14.77 14.85 15.11 15.38 15.57 15.85 16.78 18.03 18.64 19.46 19.74 20.19 21.85 22.22 22.81 23.14 23.30 24.19 24.32 26.24 26.32 33.74 33.85 37.58 0 10 20 30 40 50 60 70 80 90 Maluku Papua Barat DKI Jakarta Sumatera Utara Papua Kalimantan Barat Bengkulu Bangka Belitung Kalimantan Selatan Jawa Barat Kalimantan Tengah Maluku Utara DI Aceh Riau Sulawesi Utara Lampung Sumatera Selatan Sulawesi Tenggara Indonesia Sulawesi Selatan Jawa Tengah Kalimantan Timur Nusa Tenggara Timur Sulawesi Barat Jambi DI Yogyakarta Banten Sumatera Barat Gorontalo Jawa Timur Bali Sulawesi Tengah Kepulauan Riau Nusa Tenggara Barat

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

19

(20)

Health & Nutrition Status of

Pregnant Women

(21)

Pregnant women + hypertension, 2007

5.8 7.0 9.8 12.5 18.1 25.0 44.0 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 H ip er ten si (% )

Umur Ibu hamil (Tahun)

(22)

Pregnant women + hypertension, 2013

6.3 3.1 0 1 2 3 4 5 6 7

Hypertension Diagnosed hypertension

(23)

Pregnant women + DM, 2007

0.50 0.45 0.36 0.50 0.73 1.64 0.52 0.00 0.40 0.80 1.20 1.60 2.00 15-19 20-24 25-29 30-34 35-39 40-44 45-49 D iab etes (% )

Umur Ibu Hamil

(24)

Pregnant women + Malaria, 2007

2.4 2.5 2.4 2.4 3.5 4.4 6.2 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 M al ar ia (% )

Umur Ibu hamil (tahun)

(25)

Proportion of Anemia in Pregnant Women by urban/rural, 2013 36.4 37.8 37.1 0.0 10.0 20.0 30.0 40.0 50.0

Perkotaan Perdesaan INDONESIA

*) Nilai rujukan menurut WHO/MNH/NHD/MNN/11.1,2011 dan Kemenkes,1999 **) Cut off points anemia Ibu Hamil, Hb < 11,0 g/dl

(26)

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

(27)

Energy intake of pregnant women

87.5 42.4 70 44.4 67.2 51.8 _50.1 67.2 45.3 79.2 47.5 71.2 80.1 69.8 65.2 0 20 40 60 80 100 120 < 20 20 - 24 25 - 29 30 - 34 ≥ 35 Trimester 1 Trimester 2 Trimester 3

(28)

67.2 39.2 34.2 50.1 30.5 46.9 _44.8 48.1 49.4 49.8 70.2 48.4 56.9 58.2 _55.8 0.0 20.0 40.0 60.0 80.0 100.0 120.0 < 20 20 - 24 25 - 29 30 - 34 ≥ 35 Trimester 1 Trimester 2 Trimester 3

Protein intake of pregnant women

(29)

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

0 10 20 30 40 Terlalu muda <20 tahun Terlalu tua >35 tahun Terlalu dekat <2 tahun Terlalu banyak >4 anak 8.4 12.1 33.7 7.1 Source: Riskesdas 2013

(30)

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

3 1 .3 2 3 .8 1 6 .1 1 2 .7 1 2 .6 1 0 .3 5 .6 3 0 .9 1 8 .2 1 3 .1 1 0 .2 8 .9 7 .9 ₈.1 0.0 10.0 20.0 30.0 40.0 50.0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 2007

Hamil Tidak Hamil

3 8 .5 3 0 .1 2 0 .9 2 1 .4 1 7 .3 1 7 .6 20 .7 46 .6 3 0 .6 1 9 .3 1 3 .6 1 1 .3 10 .7 1 1 .8 0.0 10.0 20.0 30.0 40.0 50.0 15-19 20-24 25=29 30-34 35-39 40-44 45-49 2013

Hamil Tidak Hamil

(31)

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

kg

2,4 kg mgg

Tahun 2013: N = 220 ibu hamil**

9.0 10.3 10.7 9.1 7.3 -1.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 4 8 12 16 20 24 28 32 36 37 38 39 40 < 150 Cm ≥ 150 Cm IOM 2009

(32)

Pregnant women: weight gain vs body weight before pregnant 8.2 10.0 10.7 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 4 8 12 16 20 24 28 32 36 37 38 39 40 BBPH < 45 BBPH ≥ 45 kg IOM 2009

(33)

(34)

Mother’s education vs

maternal health services, SDKI 2012

Pendidikan Ibu Periksa Hamil dengan Nakes Mendapat Pil Zat Besi Persalinan di Faskes Penolong persalinan dg Nakes Kunjungan Nifas (1-2 hari) Tidak Sekolah 64.0 36.7 21.1 31.8 38.8 Tidak tamat SD 88.5 61.5 38.0 61.1 66.5 Tamat SD 94.0 70.4 47.1 72.8 75.9 Tidak Tamat SLTP 97.4 77.6 61.0 85.7 78.5 Tamat SLTP 98.4 80.0 79.8 94.3 86.9 SMTA+ 99.1 86.3 86.4 96.8 89.5 Source: Atmarita, 2013

(35)

Economic status vs maternal health services, SDKI 2012 Status Ekonomi Periksa Hamil dengan Nakes Mendapat Pil Zat Besi Persalinan di Faskes Penolong persalinan dg Nakes Kunjungan Nifas (1-2 hari) Terbawah 86.9 61.6 29.7 57.5 59.3 Menengah Bawah 95.8 74.8 57.2 81.8 82.4 Menengah 97.7 77.5 66.2 89.7 83.5 Menengah Atas 99.0 79.5 79.1 93.2 85.3 Teratas 99.4 84.6 88.1 96.6 91.1 Source: Atmarita, 2013

(36)

Total Fertility Rate: 1981-2012

4.3 3.3 3.02 2.85 _2.78 2.6 _2.6 2.6 3.7 2.8 2.6 2.31 2.4 2.4 2.3 2.4 4.5 3.6 3.24 3.15 2.98 2.7 2.8 2.8 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 1981-1983 1984-1987 1988-1991 1992-1994 1995-1997 1998-2002 2003-2007 2008-2012 TFR Reference Period Kota+Desa Kota Desa Source: IDHS 1991 - 2012

(37)

Age of married status

Proporsi Remaja/Dewasa Muda Menurut

Tempat Tinggal dan Status Kawin, Riskesdas 2010

Jenis Kelamin Kelompok Umur (Tahun) Kota Desa Belum Kawin Kawin Belum Kawin Kawin Laki-laki 10-14 99,9 0,1 99,9 0,1 15-19 98,7 1,3 97,8 2,2 20-24 82,9 17,1 71,7 28,3 Perempuan 10-14 99,9 0,1 99,7 0,3 15-19 92,8 7,2 82,5 17,5 20-24 46,9 53,1 14,4 85,6

(38)

(39)

Maternal health care

• Stated as the priority in health

development

• Crash program of midwife education 

posted midwife in each village

• Maternal health insurance (Jampersal),

now integrated into National Health Insurance Scheme of Indonesia

• Increasing the role and capability of

midwife: education & training

• Decreasing the role TBA (Traditional Birth

(40)

Maternal health care

• Increasing the BEONC Health Center

• Increasing the CEONC Hospital

• Improving the quality of services both in

Health Center and Hospital

• Increasing the coverage of CPR

(Contraception prevalence rate)

• Increasing the coverage of maternal

health services

• Health promotion for mothers and

(41)

(42)

Conclusion

• MMR in Indonesia still high  need work

hard to decrease MMR

• Coverage of maternal health services is

increasing

• Poor quality of health services 

improving quality of services is a must

• Health & Nutrition status of pregnant

women not yet optimum  need

innovative action

• Multi-sector interventions should be done

(43)

Nutrition, Health Status, Programs and Policy for Pregnant and Lactating Women in Indonesia