Nutrition, Health Status, Programs and Policy for Pregnant and

Nutrition, Health Status,
Programs and Policy for
Pregnant and Lactating Women
in Indonesia
Trihono
Senior Health Advisor
Jakarta, 12 August 2014
Email: [email protected]
Outline of Presentation
1.
2.
3.
4.
Maternal Mortality Ratio (MMR)
Coverage of maternal health services
Quality of maternal health services
Health & nutrition status of pregnant
women
5. Policy & programs
6. Conclusion
 Focus on pregnant women
Email: [email protected]
Maternal Mortality Ratio
in Indonesia
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Source: Prof. Terence H Hull
MMR 1994 - 2012
500
MMR/100.000 LH
400
390
359
334
307
300
228
200
100
0
1989-1994
Source: IDHS 1994 - 2012
1993-1997
1998-2002
2003-2007
Reference Period
2008-2012
Email: [email protected]
Source: IDHS 1994 - 2012
Email: [email protected]
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
done, the results i.e.:
Email: [email protected]
Cause of Maternal Mortality (Population Census 2010)
Kode ICD 10,
WHO
O00-O08
Underlying cause of
maternal death
Pregnancy with abortive
outcome
O10-O16
O44-O46
Region
Kalimantan Sulawesi
2.7
5.6
Jawa-Bali
4.2
Oedema, proteinuria, and
hypertensive disorder (HDK)
33.3
33.1
34.9
32.6
25.8
32.4
32.4
Placenta previa, premature
separation of placenta and
Antepartum haemorrhage
Other maternal care related
to fetus and amniotic cavity
and possible delivery
problems
4.4
2.7
4.3
2.3
3.6
3.3
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
20.3
O20-O29, O60O63, O67-O71,
O73-O75, O81O84
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
100.0
(N=1737)
100.0
(N=3334)
100.0
(N=587)
100.0
(N=979)
O30-O43, O47O48
Total
IBT
4.2
Indonesia
Sumatera
3.7
4.1
100.0
1000
(N=887) (N=7524)
Period of Maternal Death
Period
N
(%)
Pregnant < 20 weeks
543
7.2
Pregnant > 20 weeks
1,372
18.2
974
12.9
Post partum
4,634
61.6
Total
7,523
100.0
Labor
Source: Follow up study of maternal mortality of PC 2010
Email: [email protected]
Place of Maternal Death
13%
16%
42%
Government Hospital
Home
29%
Private Hospital
Others
Source: Follow up study of maternal mortality of PC 2010
Email: [email protected]
Coverage of
Maternal Health Services
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Coverage of ANC, 1991 - 2012
100.0
Kunjungan ANC (%)
80.0
55.1
63.1
70.4
81.0
60.0
81.5
87.8
4+
2-3
1
40.0
0
20.0
0.0
1991
1994
Source: IDHS 1991 - 2012
1997
2002
Reference period
2007
2012
Email: [email protected]
Maluku
Papua
Pabar
Malut
Sulbar
Sulteng
Kalteng
Sultra
Gorontalo
NTT
Sulsel
Kalbar
Sumsel
Sumut
Jambi
Sulut
Kalsel
Aceh
Bengkulu
Sumbar
Riau
Kaltim
Banten
INDONESIA
Babel
NTB
Jabar
Jatim
Lampung
Kep.Riau
DKI
Jateng
Bali
DIY
Coverage of ANC-4 by Provinces, 2010 - 2013
100.0
80.0
70.0
60.0
61.4
40.0
20.0
0.0
2010
Source: Riskesdas 2010 - 2013
2013
Email: [email protected]
Papua
Maluku
Malut
Sulbar
NTT
Pabar
Kalteng
Sulteng
Kalbar
Sultra
Sulsel
Sulut
Jabar
Banten
Kalsel
Riau
INDONESIA
Jambi
Sumsel
Lampung
Kaltim
Babel
Aceh
Gorontalo
NTB
Sumbar
Sumut
Jatim
Bengkulu
Kep.Riau
Jateng
DKI
Bali
DIY
Coverage of SBA: 2010 - 2013
100.0
86.9
80.0
79.0
60.0
40.0
20.0
0.0
2010
2013
Source: Riskesdas 2010 - 2013
Email: [email protected]
Maluku
Papua
Pabar
NTT
Malut
Sulbar
Kalbar
Kalteng
Sulteng
Jabar
Kep.Riau
Lampung
Sumsel
Sultra
Banten
Sulut
Sulsel
INDONESIA
Babel
Sumbar
Kalsel
Riau
Kaltim
Sumut
Aceh
Jambi
Jatim
NTB
Gorontalo
Jateng
DKI
Bali
Bengkulu
DIY
Coverage of PNC: 2010 - 2013
100.0
81.7
80.0
60.0
40.0
46.8
20.0
0.0
2010
Source: Riskesdas 2010 - 2013
2013
Email: [email protected]
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
3. Other social determinants
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Quality of
Maternal Health Services
Email: [email protected]
0.0
BALI
DI YOGYAKARTA
JAMBI
DKI JAKARTA
NUSA TENGGARA TIMUR
JAWATENGAH
JAWATIMUR
BANTEN
NUSA TENGGARA BARAT
JAWABARAT
RIAU
SUMATERA SELATAN
SUMATERABARAT
KALIMANTAN BARAT
LAMPUNG
KALIMANTAN TIMUR
GORONTALO
SULAWESI TENGAH
SULAWESI SELATAN
SUMATERAUTARA
PAPUA
KEP. RIAU
ACEH
KALIMANTAN TENGAH
SULAWESI UTARA
KALIMANTAN SELATAN
BENGKULU
KEP. BANGKA BELITUNG
SULAWESI TENGGARA
SULAWESI BARAT
MALUKU
MALUKUUTARA
PAPUABARAT
INDONESIA
Proportion of CEONC (Comprehensive Emergency
Obstetric & Neonatal Care) Hospital
100.0
90.0
80.0
70.0
60.0
50.0
40.0
30.0
21.0
20.0
10.0
Sumber: Riset Fasilitas Kesehatan 2011
Email: [email protected]
Proportion of BEONC (Basic Emergency Obstetric &
Neonatal Care) Health Center
Nusa Tenggara Barat
Kepulauan Riau
Sulawesi Tengah
Bali
Jawa Timur
Gorontalo
Sumatera Barat
Banten
DI Yogyakarta
Jambi
Sulawesi Barat
Nusa Tenggara Timur
Kalimantan Timur
Jawa Tengah
Sulawesi Selatan
Indonesia
Sulawesi Tenggara
Sumatera Selatan
Lampung
Sulawesi Utara
Riau
DI Aceh
Maluku Utara
Kalimantan Tengah
Jawa Barat
Kalimantan Selatan
Bangka Belitung
Bengkulu
Kalimantan Barat
Papua
Sumatera Utara
DKI Jakarta
Papua Barat
Maluku
37.58
33.85
33.74
26.32
26.24
24.32
24.19
23.30
23.14
22.81
22.22
21.85
20.19
19.74
19.46
18.64
18.03
16.78
15.85
15.57
15.38
15.11
14.85
14.77
14.35
14.29
14.04
13.87
13.73
13.61
13.44
10.71
10.58
10.56
0
10
20
Sumber: Riset Fasilitas Kesehatan 2011
30
40
50
60
70
80
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19
Health & Nutrition Status of
Pregnant Women
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Pregnant women + hypertension, 2007
50.0
44.0
45.0
40.0
Hipertensi (%)
35.0
30.0
25.0
25.0
18.1
20.0
15.0
10.0
12.5
9.8
5.8
7.0
15-19
20-24
5.0
0.0
Source: Riskesdas 2007
25-29
30-34
35-39
Umur Ibu hamil (Tahun)
40-44
45-49
Email: [email protected]
Pregnant women + hypertension, 2013
7
6.3
6
5
4
3.1
3
2
1
0
Hypertension
Source: Riskesdas 2013
Diagnosed hypertension
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Pregnant women + DM, 2007
2.00
1.64
Diabetes (%)
1.60
1.20
0.73
0.80
0.50
0.45
0.40
0.52
0.50
0.36
0.00
15-19
20-24
Source: Riskesdas 2007
25-29
30-34
Umur Ibu Hamil
35-39
40-44
45-49
Email: [email protected]
Pregnant women + Malaria, 2007
7.0
6.2
6.0
5.0
Malaria (%)
4.4
4.0
3.5
3.0
2.4
2.5
15-19
20-24
2.4
2.4
2.0
1.0
0.0
Source: Riskesdas 2007
25-29
30-34
35-39
Umur Ibu hamil (tahun)
40-44
45-49
Email: [email protected]
Proportion of Anemia in Pregnant Women
by urban/rural, 2013
50.0
40.0
36.4
37.8
37.1
Perdesaan
INDONESIA
30.0
20.0
10.0
0.0
Perkotaan
*) Nilai rujukan menurut WHO/MNH/NHD/MNN/11.1,2011 dan Kemenkes,1999
**) Cut off points anemia Ibu Hamil, Hb < 11,0 g/dl
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Nutrition status of pregnant women, weight gain
during pregnancy (kg)
Source: Cohort study on child growth & development, 2013
Email: [email protected]
Energy intake of pregnant women
120
100
87.5
80
60
67.2
80.1
71.2
47.5
51.8
70
79.2
69.8
67.2 65.2
45.3
44.4
50.1
42.4
Trimester 1
Trimester 2
40
Trimester 3
20
0
< 20
20 - 24
25 - 29
30 - 34
Source: Cohort study on child growth & development, 2013
≥ 35
Email: [email protected]
Protein intake of pregnant women
120.0
100.0
80.0
67.2 70.2
60.0
39.2
55.8
50.1
48.4
40.0
20.0
58.2
56.9
34.2
Trimester 1
Trimester 2
30.5
46.9
44.8
48.1
49.4
49.8
< 20
20 - 24
25 - 29
30 - 34
≥ 35
Trimester 3
0.0
Source: Cohort study on child growth & development, 2013
Email: [email protected]
Proportion of too young, too old, too close
between pregnancies, too many children, 2013
33.7
40
30
20
8.4
12.1
7.1
10
0
Terlalu muda
<20 tahun
Source: Riskesdas 2013
Terlalu tua >35
tahun
Terlalu dekat
<2 tahun
Terlalu banyak
>4 anak
Email: [email protected]
Proportion reproductive women with risk
of chronic malnourish : 2007 & 2013
2013
40.0
40.0
30.1
30.6
0.0
11.8
20.7
17.6
11.3
17.3
21.4
20.9
19.3
13.6
10.7
5.6
8.1
10.3
7.9
12.6
8.9
10.0
20.0
12.7
10.2
16.1
13.1
18.2
20.0
30.0
23.8
30.0
38.5
50.0
31.3
30.9
50.0
46.6
2007
10.0
0.0
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Hamil
Tidak Hamil
Source: Riskesdas 2007 & 2013
15-19 20-24 25=29 30-34 35-39 40-44 45-49
Hamil
Tidak Hamil
Email: [email protected]
Pregnant women: weight gain vs height (N=220)
12.0
11.0
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
-1.0
10.7
10.3
9.0
kg
9.1
2,4 kg
7.3
mgg
Tahun 2013: N = 220 ibu hamil**
4
8
12
16
< 150 Cm
20
24
28
32
≥ 150 Cm
Source: Cohort study on child growth & development, 2013
36
37
38
39
40
IOM 2009
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Pregnant women: weight gain vs body weight
before pregnant
12.0
11.0
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
10.7
10.0
8.2
4
8
12
16
BBPH < 45
20
24
28
32
BBPH ≥ 45 kg
Source: Cohort study on child growth & development, 2013
36
37
38
39
40
IOM 2009
Email: [email protected]
Other determinants
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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
Email: [email protected]
Economic status vs maternal health services,
SDKI 2012
Status Ekonomi
Periksa
Hamil
dengan
Nakes
Penolong
Kunjungan
Mendapat Pil Persalinan di
persalinan dg Nifas (1-2
Zat Besi
Faskes
Nakes
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
Email: [email protected]
Total Fertility Rate: 1981-2012
5
4.5
4.5
4
4.3
3.6
3.24
3.5
TFR
3
2.5
3.7
3.15
3.3
2.98
3.02
2.8
2
2.8
2.7
2.85
2.78
2.31
2.4
2.6
2.6
2.4
2.6
2.8
2.6
2.4
2.3
1.5
1
0.5
Kota+Desa
Kota
Desa
0
1981-1983 1984-1987 1988-1991 1992-1994 1995-1997 1998-2002 2003-2007 2008-2012
Reference Period
Source: IDHS 1991 - 2012
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Age of married status
Proporsi Remaja/Dewasa Muda Menurut
Tempat Tinggal dan Status Kawin, Riskesdas 2010
Jenis
Kelamin
Kota
Kelompok
Umur
Belum
(Tahun) Kawin Kawin
10-14
Laki-laki 15-19
20-24
10-14
Perempuan 15-19
20-24
99,9
98,7
82,9
99,9
92,8
46,9
0,1
1,3
17,1
0,1
7,2
53,1
Desa
Belum
Kawin
Kawin
99,9
97,8
71,7
99,7
82,5
14,4
0,1
2,2
28,3
0,3
17,5
85,6
Email: [email protected]
Policy and Programs
Email: [email protected]
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
Attendance)
Email: [email protected]
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
adolescents.
Email: [email protected]
Conclusion
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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
in very good coordination
Email: [email protected]
Thank you
Terima kasih
Email: [email protected]