Kebijakan & Strategi MCH di Indonesia. Titik Kuntari Departemen Ilmu Kesehatan Masyarakat FK UII

Kebijakan & Strategi MCH

di Indonesia

Titik Kuntari

Kematian Maternal?

• =kematian yang dialami seorang perempuan yang

sedang hamil atau dalam 42 hari setelah terminasi

kehamilan, oleh sebab- sebab terkait kehamilan atau

manajemennya tetapi bukan karena kecelakaan

PR

• Menurunkan AKB menjadi 2/3 nya pada tahun

2015. 32 kematian per 1000 kelahiran hidup pada tahun 2015.

• Menurunkan AKI sebesar ¾ nya antara tahun 1990 dan 2015,97 kematian per 1000 kelahiran hidup.

Menurunkan AKI

• Target menjadi ¾ dari AKI tahun 1990 belum tercapai

• AKI Indonesia tertinggi se Asia Tenggara (SDKI 2012-2013)

Penyebab

• Direct

• Those resulting from obstetric complications of the pregnant state (pregnancy, labour and the puerperium), from interventions,

omissions, incorrect treatment or from a chain of events resulting from any of the above

• Indirect

• Those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but was aggravated by physiologic effects of pregnancy

Penyebab Kematian Ibu

24,8 14,9 12,9 6,9 12,9 7,9 19,8 Hemorrhage 24.8% Infection 14.9% Eclampsia 12.9% Obstructed Labor 6.9% Unsafe Abortion 12.9% Other Direct Causes 7.9%

Indirect Causes 19.8%

Faktor Risiko – 4 Terlalu

• Usia Ibu = terlalu TUA, terlalu MUDA • Paritas (terlalu Banyak)

• Jarak persalinan (terlalu Sering) “ Unwanted pregnancy “

Causal Pathways in the Reduction of

Maternal Mortality

• Reduce the likelihood that a woman will become pregnant • Reduce the likelihood that a pregnant woman will

experience a serious complication of pregnancy or childbirth • Reduce the likelihood of death among women who

Program di Indonesia

• Cegah/ tunda kehamilan  KB • ANC

• Pendampingan dan pelatihan dukun bayi • Desa siaga

• Peningkatan kualitas Nakes pelatihan nakes, bidan delima • Peningkatan mutu faskes

Safe Motherhood

• “ A woman’s ability to have a SAFE and healthy

Four pillars of safe motherhood

EQUITY FOR WOMEN PRIMARY HEALTH CARE

fami ly planni ng essenti al ob stetric care

basic maternity care

antenatal care clean

& safe de liver y safe motherhood WHO 1998

Perubahan

•Pada kurun waktu 1970-an hingga 1990-an,  aspek demografis semata yaitu pengendalian angka kelahiran. •Pasca ditandatanganinya International Conference on

Population and Development (ICPD) di Cairo Tahun 1994, telah terjadi pergeseran paradigma yang cukup signifikan

dalam pelaksanaan program KB yaitu dari pendekatan

demografis menjadi mengedepankan aspek hak-hak asasi manusia.

Undang-Undang Nomor 10 Tahun 1992 tentang Perkembangan Kependudukan dan Pembangunan

Keluarga Sejahtera

Undang Nomor 52 Tahun 2009 tentang

perkembangan Kependudukan dan Pembangunan Keluarga  Keluarga Berencana adalah upaya

mengatur kelahiran anak, jarak dan usia ideal melahirkan, mengatur kehamilan melalui promosi,

perlindungan dan bantuan sesuai dengan hak

Interventions:

Traditional Birth Attendants

Advantages

• Community-based

• Sought out by women

• Low tech

• Teaches clean delivery

Disadvantages

• Technical skills limited

• May keep women away

from life-saving

interventions due to

false reassurance

Interventions: Antenatal Care

• Antenatal care clinics started in US, Australia, Scotland between 1910–1915

• New concept - screening healthy women for signs of disease • By 1930’s large number (1200) ANC clinics opened in UK

• No reduction in maternal mortality

• However, widely used as a maternal mortality reduction strategy in 1980’s and early 1990’s

Is ANC important? YES!!

Maternal Mortality: UK 1840–1960

0 50 100 150 200 250 300 350 400 450 500 1840 1850 1860 1870 1880 1890 1900 1910 1920 1930 1940 1950 1960 Maternal Deaths Improvements in nutrition, sanitation

Antibiotics, banked blood, surgical improvements Antenatal

care

Interventions: Skilled Attendant at Childbirth

• Proper training, range of skills • Assess risk factors

• Recognize onset of complications

• Observe woman, monitor fetus/infant • Perform essential basic interventions

• Refer mother/baby to higher level of care if complications arise requiring interventions outside realm of competence • Have patience and empathy

R2 = 0.74 0 200 400 600 800 1000 1200 1400 1600 1800 2000 0 10 20 30 40 50 60 70 80 90 100 Y Log. (Y)

The higher the proportion of deliveries

attended by skilled attendant in a country, the lower the country’s maternal mortality ratio

% skilled attendant at delivery

Ma ternal de aths pe r 1000000 liv e b irt hs

Summary

Skilled attendant at

childbirth is the most

effective intervention

Program memperbaiki kesehatan anak

• Imunisasi

• Rehidrasi oral • MTBS

PONEK

Ponek adalah pelayanan obstetri neonatal esensial / emergensi komperhensif. Tujuan utama mampu menyelamatkan ibu dan anak baru lahir melelui

program rujukan berencana dalam satu wilayah kabupaten kotamadya atau profinsi.

Upaya Pelayanan PONEK :

1. Stabilisasi di UGD dan persiapan untuk pengobatan definitif

2. Penanganan kasus gawat darurat oleh tim PONEK RS di ruang tindakan 3. Penanganan operatif cepat dan tepat meliputi laparotomi, dan SC

4. Perawatan intensif ibu dan bayi.

PONED ( Pelayanan Obstetri Neonatus

Essensial Dasar )

• PONED merupakan kepanjangan dari Pelayanan Obstetri Neonatus Essensial Dasar.

• PONED dilakukan di Puskesmas induk dengan pengawasan dokter.

• Petugas kesehatan yang boleh memberikan PONED yaitu dokter, bidan, perawat dan tim PONED Puskesmas beserta penanggung jawab terlatih. • Pelayanan Obstetri Neonatal Esensial Dasar dapat dilayani oleh puskesmas

yang mempunyai fasilitas atau kemampuan untuk penangan kegawatdaruratan obstetri dan neonatal dasar.

• Puskesmas PONED merupakan puskesmas yang siap 24 jam, sebagai

rujukan antara kasus-kasus rujukan dari polindes dan puskesmas. Polindes dan puskesmas non perawatan disipakan untuk mealkukuan pertolongan pertama gawat darurat obstetri dan neonatal (PPGDON) dan tidak

• Target utama  mengentaskan kemiskinan • Indonesia menggunakan 3 indikator

1. Pembangunan manusia (human development) – pendidikan dan kesehatan

2. Lingkungan dalam skala kecil (social economic development) 3. Lingkungan besar (environmental development)– ketersediaan

SDG’s 2016-2030

• Tujuan ketiga (13 target), yakni menjamin kehidupan yang sehat dan mendorong kesejahteraan bagi semua orang di segala usia.

TARGETS

• 3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births

• 3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births

• 3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical

diseases and combat hepatitis, water-borne diseases and other communicable diseases • 3.4 By 2030, reduce by one third premature mortality from non-communicable diseases

• 3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

• 3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents

• 3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes • 3.8 Achieve universal health coverage, including financial risk protection,

access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all

• 3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination

• 3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate

• 3.b Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in

accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all

• 3.c Substantially increase health financing and the recruitment, development,

training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States

• 3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks