1. THE ROAD TO
MATERNAL DEATH
Biran Affandi
Klinik Raden Saleh
Department of Obstetrics and Gynecology
Faculty of Medicine , University of Indonesia /
Cipto Mangunkusumo General Hospital
Jakarta
Affandi B. The Road to Maternal Death . POKJANAS PONE , Jakarta , 29 August 2012

2. OBJECTIVES
1. To overview Millennium
Development Goals
2. To review Status of Maternal &
Neonatal Health in Indonesia
3. To discuss ways in Improving
Maternal Health in Indonesia
Affandi B. The Road to Maternal Death . POKJANAS PONE , Makassar 19 Juli 2011

3. MELLINIUM DEVELOPMENT GOALS(MDGs)
Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011

4. GOAL 4: Reduce child mortality
Family planning saves infant lives.
Spacing births and limiting
unintended births increases child
survival.
•Currently, 2.7 million infant deaths
are averted each year by the
prevention of unintended
pregnancies.
Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011

5. PROGRESS INDONESIA (4/8)
4. Menurunkan Angka Kematian Anak  menjadi 1/3-nya (2015)
Tantangan:
-Sebab kematian pada anak (ISPA, komplikasi perinatal, &
diare)
-Kesehatan neonatal & maternal
-Perlindungan & Pelayanan Kesehatan
-Penerapan desentralisasi kesehatan

7. MMR in Indonesia, Selected other
countries
700
620
600
500 440
400 Indonesia
350
India
300 270
240 Vietnam
200 SE asia
100
0
1990 1995 2000 2005 2008
Indonesia: 62% decline on 1990 levels, 5.4% annual change
7 Trends In Maternal Mortality 1990-2008, Source: WHO , 2010

8. MDG 5: Improve maternal health
– Target 5a: Reduce the maternal mortality ratio by ¾ (75%)
• Indicator 5.1 Maternal mortality ratio (MMR)
• Indicator 5.2 Proportion of births attended by skilled
health personnel
– Target 5b: Achieve universal access to reproductive health
by 2015
• Indicator 5.3 Contraceptive prevalence rate (CPR)
• Indicator 5.4 Adolescent birth rate
• Indicator 5.5 Antenatal care coverage
• Indicator 5.6 Unmet need for family planning
Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011

9. PROGRESS INDONESIA (5/8)
5. Meningkatkan Kesehatan Ibu  menurunkan angka kematian ¾-nya
Tantangan:
-Struktur penduduk  proporsi wanita subur tinggi meningkatkan kebutuhan lynn
kesehatan
-Penerapan desentralisasi kesehatan
-Keterbatasan biaya & tenaga

11. Persalinan 1 tahun terakhir oleh Nakes menurut Provinsi 2010
Sumber: Riskesdas 2010 11

12. Proporsi Persalinan menurut Tempat Melahirkan
70.0
60.0 55.4
50.0 43.2
Persen
40.0
30.0
20.0
10.0
1.4
0.0
Fasilitas kesehatan Polindes/Poskesdes Rumah/Lainnya
Tempat Melahirkan
• 51,9% persalinan ditolong bidan
• 40,2% ditolong dukun
Sumber : Riskesdas 2010
12

13. Kesenjangan Pelayanan Antenatal
K1 & K4
92.8
100
80 61.3
60
40
20
0
K1 K4
Sumber: Riskesdas 2010
13

14. • Maternal mortality is an
indicator of gross
inequality, human rights abuse
and development failure.
• “All maternal health problems
are preventable as long as the
government pays attention and
prioritizes maternal health.”
Dr. S.T.Mathai, UNFPA , The Jakarta Post , 13 Jan. , 2010
Affandi B. Kesehatan Reproduksi dan Upaya Kesehatan Maternal di Indonesia , Quo Vadis ? Orasi pada PIT XVIII-POGI , Jakarta , 7 Juli 2010

15. •Of the 11 countries that contribute to 65
percent to global maternal death, five are in
Asian countries including
Indonesia, Bangladesh, Pakistan , India and
Afghanistan.
•A high maternal mortality rate is an
indicator of the status of poor functioning of
a country’s health system including lack of
supportive and protective legal and policy
environment.
Dr. S.T.Mathai, UNFPA , The Jakarta Post , 13 Jan. , 2010
Affandi B. Kesehatan Reproduksi dan Upaya Kesehatan Maternal di Indonesia , Quo Vadis ? Orasi pada PIT XVIII-POGI , Jakarta , 7 Juli 2010

17. Women's status
• As measured by indicators such as level of
education relative to men, age at first
marriage, and reproductive autonomy, is a strong
predictor of maternal mortality.
• Economic dependency, especially multinational
corporate investment, has a detrimental effect on
maternal mortality that is mediated by its harmful
impacts on economic growth and the status of
women.
• Support for developmental theory, a variant of
modernization theory. Shen & Williamson . Soc Sci Med. 1999, 49:197-214

18. Three-pronged strategy
to reducing maternal mortality
■ Family planning to ensure that every birth is
wanted
■ Skilled care by a health professional with
midwifery skills for every pregnant woman
during pregnancy and childbirth
■ Emergency Obstetric Care (EmOC) to ensure
timely access to care for women experiencing
complications. UNFPA , 2009

19. MOST POPULOUS COUNTRIES , 2009
COUNTRY POPULATION (Million)
1. China 1,346
2. India 1,198
3. U.S.A. 315
4. Indonesia 230
5. Brazil 194
Sources: United Nations (2009), World Population Prospect: The 2008 Revision;
Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010

20. POPULATION IN INDONESIA
(Million) 330 million
300.00
285 million
275.00 FAMILY PLANNING
FAMILY PLANNING REDUCED
250.00 REDUCED 100 MILLION
80 MILLION
225.00
230 m
200.00
205 m
175.00
150.00
125.00
100.00
75.00
50.00 40.2
25.00 10.8 14.2 18.3
0.00
1600 1700 1800 1900 2000 2009
Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010

21. CONTRACEPTIVE PREVALENCE
INDONESIA , 1970-2007
80
70 61.4 %
60 %
57 %
60
48 %
50
40
26 %
30
20
5 % (?)
10
0
1970 1980 1987 1997 2002 2007
Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010

22. PERENCANAAN KELUARGA
1. Seorang wanita telah dapat melahirkan, segera
setelah ia mendapat haid yang pertama
(menarche)
2. Kesuburan seorang wanita akan terus
berlangsung, sampai mati haid (menopause)
3. Kehamilan dan kelahiran yang terbaik, artinya
risiko paling rendah untuk ibu dan anak, adalah
antara 20-35 tahun
4. Persalinan pertama dan kedua paling rendah
risikonya
5. Jarak antara dua kelahiran sebaiknya 2-4 tahun
Affandi, 1984

23. POLA PERENCANAAN KELUARGA
Fase Fase Fase
Menunda Menjarangkan Tidak Hamil
Kehamilan Kehamilan lagi
2-4
20 35
Affandi, 1984

24. CONTRACEPTIVE METHODS
RATIONALE CHOICE
Phase Phase Phase
DIFFERING SPACING COMPLETING
2-4
- Pill - IUD - IUD - Steril
- IUD - Inject. - Inject. - IUD
- Conventional - Pill - Pill - Pill
20 35 - Implant
- Inject. - Implant - Implant
- Implant - Conventional - Conventional - Inject.
- Steril - Conventional
Affandi, 1984

25. BIRTH RATE
STILL HIGH ! ! !
4.5 – 5 Million/year
Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010

26. FAKTA
1.Pascasalin OVULASI dapat
terjadi dalam waktu 21 hari
2.Pascakeguguran OVULASI
dapat TERJADI dalam waktu
11hari
Contraceptive choices for breastfeeding women .Journal of Family Planning and Reproductive Health Care 2004; 30(3): 181–189
Affandi B. Kontrasepsi Terkini dan IUD Pascaplasenta . Pertemuan Koordinasi Peningkatan KB Pascapersalinan di Rumah Sakit , Makassar 31 Agustus 2010

28. IUD-Cu
Affandi B. Perkembangan Kontrasepsi, Teknik Penapisan dan KB Postpartum , BPMPPKB, Balikpapan , 24 Juni 2010

29. • The postpartum insertion of IUDs has
a number of advantages, including
ease of insertion, availability of skilled
personnel and appropriate
facilities, and convenience for the
woman.
• Practitioners have been concerned
about the possibility of higher
expulsion, infection and perforation
www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm
rates.
Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010

30. • Postplacental (preferably within
10 minutes after expulsion of the
placenta) and immediate
postpartum insertion during the
first week after delivery (but
preferably within 48 hours) are
convenient effective and safe
times to insert copper IUDs.
{Managing Contraception 2005-2007, page 92}
Affandi B. Perkembangan Kontrasepsi, Teknik Penapisan dan KB Postpartum , BPMPPKB, Balikpapan , 24 Juni 2010

31. Teknik Pemasangan AKDR
Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010

32. Fundal placement
• The way the IUD is inserted is more important than
the design of the device.
• Differences in IUD expulsion rates between centers
participating in the trials were generally greater than
expulsion rates for different IUDs;
• FHI data show that emphasis needs to be given to the
fundal placement of the device.
• The provider should be able to feel the device through
the abdominal and uterine walls at the time of
insertion.
• Retraining is necessary for those individuals who
report high expulsion rates www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm
Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010

33. Teknik Pemasangan AKDR
Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010

34. Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010

35. Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010

36. Statement , WHO-Geneva , 22 Oct. 2008:
Progestin-only contraceptive use during lactation
1. Use of progestin-only methods, with the exception of the
levonorgestrel bearing IUD, is not usually recommended for
women who are less than 6 weeks postpartum and
breastfeeding, unless other more appropriate methods are
unavailable or unacceptable.
2. Beyond 6 weeks postpartum, there is no restriction for the use of
progestin only contraceptive methods among breastfeeding
women.
3. The levonorgestrel-bearing IUD is not usually recommended for
the first 4 postpartum weeks, unless other more appropriate
methods are unavailable or unacceptable. Beyond 4 weeks
postpartum, there is no restriction on its use.
Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010

37. Simplified Classification of Eligibility
Criteria (WHO)
Affandi B. Perkembangan Kontrasepsi, Teknik Penapisan dan KB Postpartum , BPMPPKB, Balikpapan , 24 Juni 2010

39. Three-pronged strategy
to reducing maternal mortality
■ Family planning to ensure that every birth is
wanted
■ Skilled care by a health professional with
midwifery skills for every pregnant woman
during pregnancy and childbirth
■ Emergency Obstetric Care (EmOC) to ensure
timely access to care for women experiencing
complications. UNFPA , 2009

40. WHAT IS SKILLED ATTENDANCE AT BIRTH?
• Skilled attendance refers to professionally trained
health workers with the skills necessary to manage
a normal delivery and diagnose or refer obstetric
complications.
• This usually refers to a doctor, midwife or nurse.
• Skilled attendants must be able to manage a normal
labour and delivery, recognize complications early
on and perform any essential interventions, start
treatment, and supervise the referral of mother and
baby to the next level of care if necessary.
• Trained and untrained traditional birth attendants
(TBAs) are not included in this category.
(WHO/UNFPA/UNICEF/WORLD BANK. JOINT STATEMENT FOR REDUCING MATERNAL MORTALITY, 1999. )

41. Ronsmans et al. Bulletin WHO 2009;87:416-423

42. Ronsmans et al. Bulletin WHO 2009;87:416-423

43. Ronsmans et al. Bulletin WHO 2009;87:416-423

44. Three-pronged strategy
to reducing maternal mortality
■ Family planning to ensure that every birth is
wanted
■ Skilled care by a health professional with
midwifery skills for every pregnant woman
during pregnancy and childbirth
■ Emergency Obstetric Care (EmOC) to ensure
timely access to care for women experiencing
complications. UNFPA , 2009

45. Emergency Neonatology&Obstetrics Care
(EmNOC)
1. Parenteral antibiotics
2. Parenteral oxytocics
3. Parenteral anticonvulsants
4. Manual removal of the placenta
5. Removal of retained products
6. Assisted or instrumental Vaginal Delivery
7. Neonatal resuscitation
8. Blood Transfusion
9. Cesarean delivery
1-7=EmNOC Basic (PONED)
1-7+8&9=EmNOC Comprehensive (PONEK) UNFPA, WHO , 2000

46. Standard , what is it ?
• Consensus on minimum requirements
• Should include directions for quality
development
• Must be tested in evaluation studies
• A matter of specific conduct & intentional
planning
• Must be clearly
defined, meaningful, appropriate, relevant,
measurable, achievable & accepted by

47. STANDARDS
• Standards of care inform healthcare
providers about what is expected of
them and what they should do to
deliver high quality services at each
level of the healthcare system.
• Standards specify the continuum of
care that is necessary to improve
maternal and neonatal outcomes.
Johnson RH . 2001

48. • Standards promote quality care, delivered in
the most appropriate way, by the most
appropriate personnel.
• The likelihood of ensuring high quality care is
increased when skilled attendants perform
their jobs competently and their competence
is verified by comparing their performance to
evidence-based standards of care.
• Standards can empower women and
communities, giving them a tool to advocate
for improved healthcare. Johnson RH . 2001

49. Reducing Maternal and Neonatal Mortality in five
District Hospitals through Best Practices
Implementation Package - Comprehensive
Emergency Obstetrics and Neonatal Care (CEONC)
National Clinical Training Network of Indonesia
February 15, 2008-April 30, 2011
36 Months
Adriansz ,G. Presented at the Global Health Conference and ESD Consultation Meeting , Washington DC , USA , 13-17 June 2011

50. Why Comprehensive Emergency Obstetrics
and Neonatal Care?
• High MMR & NMR in Indonesia
• 42%-65% of maternal & neonatal death occurred in
hospitals
• 80% emergency cases are not stabilized and timely
referred
• Only 15% of rural and 32% of urban emergency
referral cases treated adequately in hospitals
• Although CEONC standards are endorsed by the
Ministry of Health, only 32% hospitals
institutionalized CEONC standards

51. Purpose of Intervention
• Utilize CEONC through improving the competency of
practitioners
• Enable health centers & community midwives to
recognize, stabilize, and refer emergency cases in a
timely manner
• Create emergency communication and services
network
• Build capacity of the DHO to lead and monitor the
hospital-primary health care collaboration
• Assess the Improvement Collaborative effect in
reducing MMR & NMR in hospital settings

52. Integrated CEONC Implementation
Implementing CEONC in District Referral Hospital
• JNPK-ESD was endorsed by MOH-DG of Medical Services to
implement CEONC in Tangerang District Hospitals
• CEONC was adapted from ALARM (SOGC) and Basic
Neonatal Care (HSP-USAID) by Professional Organizations &
MOH
• Conducted within MOH Health Delivery System and
accommodate Local Government Autonomy Regulation in
collaboration with Hospital and DHO (Family Health and
Service Delivery Section)
• The package also included preventive measures

53. Results on Standard of Inputs & Performance
Improved Inputs Inputs:
Input Before After infrastructures, equipments, &
Maternal 62% 90% manpower for providing CEONC
Neonatal 67% 90%
Improved Performance
Performance: management of
services, performance & quality
Performance Before After improvement, and environtmental
Maternal 67% 93% support for CEONC
Neonatal 62% 88%

54. Results on Output
Reduced Midterm Mortality*
Mortality Before After
Maternal Death 32 in 2998 12 in 3503
Maternal Mortality Ratio 800/100,000 300/100,000
Perinatal Death 85 in 2998 49 in 3503
Perinatal Mortality Ratio 42/1,000 20/1,000
Reduced Annual Mortality*
Mortality 2009 2010
Maternal Death 52 in 5002 20 in 7018
Maternal Mortality Ratio 800/100,000 300/100,000
Perinatal Death 122 in 5002 87 in 7018
Perinatal Mortality Ratio 30/1,000 16/1,000
*MMR and PMR calculated using WHO Conversion Table, Beyond the Numbers, 2004
Midterm: March - August 2009 & Annual: March 2009 - February 2010

55. Lessons Learned
• Intervention must be part of and contribute to the National Health
Development Program
• Do not create new, just fill the gap of existing effective programs which might
divert high-cost to cost-effective interventions
• The Best Practices Package must be familiar and practiced daily (starting
from what already exist and then, improved gradually)
• Implement best practices collaboratively and provide objective information
on the main goal and benefits of intervention
• Obtain good model and results before approaching health organizations or
institutions for replication
Adriansz ,G. Presented at the Global Health Conference and ESD Consultation Meeting , Washington DC , USA , 13-17 June 2011