Prof biranroadtomaternaldeathpelatihan ponek jakarta290812

THE ROAD TO MATERNAL DEATH

Biran Affandi

Klinik Raden SalehDepartment of Obstetrics and Gynecology

Faculty of Medicine , University of Indonesia /Cipto Mangunkusumo General Hospital

JakartaAffandi B. The Road to Maternal Death . POKJANAS PONE , Jakarta , 29 August 2012

OBJECTIVES1. 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

MELLINIUM DEVELOPMENT GOALS(MDGs)

Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011

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.


PROGRESS INDONESIA (4/8)4. Menurunkan Angka Kematian Anakmenjadi 1/3-nya (2015)

Tantangan:

-Sebab kematian pada anak (ISPA, komplikasi perinatal, & diare)

-Kesehatan neonatal & maternal

-Perlindungan & Pelayanan Kesehatan

-Penerapan desentralisasi kesehatan

MMR in Indonesia, Selected other countries

620

440

350

270 240

0

100

200

300

400

500

600

700

1990 1995 2000 2005 2008

Indonesia

India

Vietnam

SE asia

7 Trends In Maternal Mortality 1990-2008, Source: WHO , 2010

Indonesia: 62% decline on 1990 levels, 5.4% annual change

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


PROGRESS INDONESIA (5/8)5. Meningkatkan Kesehatan Ibumenurunkan angka kematian ¾-nya

Tantangan:

-Struktur penduduk proporsi wanita subur tinggi meningkatkan kebutuhan lynnkesehatan

-Penerapan desentralisasi kesehatan

-Keterbatasan biaya & tenaga

Persalinan 1 tahun terakhir oleh Nakes menurut Provinsi 2010

11Sumber: Riskesdas 2010

Proporsi Persalinan menurut Tempat Melahirkan

55.4

1.4

43.2

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Fasilitas kesehatan Polindes/Poskesdes Rumah/Lainnya

Per

sen

Tempat Melahirkan

Sumber : Riskesdas 201012

• 51,9% persalinan ditolong bidan• 40,2% ditolong dukun

Kesenjangan Pelayanan AntenatalK1 & K4

0

20

40

60

80

100

K1 K4

92.8

61.3

13Sumber: Riskesdas 2010

• 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

•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

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

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

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

0.00

25.00

50.00

75.00

100.00

125.00

150.00

175.00

200.00

225.00

1600 1700 1800 1900 2000

205 m

18.314.210.8

40.2

250.00

275.00

300.00

285 million

FAMILY PLANNING

REDUCED

80 MILLION

POPULATION IN INDONESIA(Million)

FAMILY PLANNING

REDUCED

100 MILLION

330 million

230 m

2009


CONTRACEPTIVE PREVALENCEINDONESIA , 1970-2007

0

10

20

30

40

50

60

70

80

1970 1980 1987 1997 2002 2007

26 %

5 % (?)

48 %

57 %60 % 61.4 %


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

POLA PERENCANAAN KELUARGA

2 - 4

20 35

Fase Fase Fase

MenundaKehamilan

MenjarangkanKehamilan

Tidak Hamil lagi

Affandi, 1984

CONTRACEPTIVE METHODSRATIONALE CHOICE

2 - 4

20 35

Phase

DIFFERING SPACING COMPLETING

- Pill - IUD- Conventional- Inject.- Implant

- IUD- Inject.- Pill - Implant- Conventional

- IUD- Inject.- Pill - Implant- Conventional- Steril

- Steril- IUD- Pill - Implant- Inject.- Conventional

Phase Phase

Affandi, 1984

BIRTH RATE

STILL HIGH ! ! !

4.5 – 5 Million/year


FAKTA1.Pascasalin OVULASI dapat

terjadi dalam waktu 21 hari

2.Pascakeguguran OVULASI dapat TERJADI dalam waktu 11hari

Affandi B. Kontrasepsi Terkini dan IUD Pascaplasenta . Pertemuan Koordinasi Peningkatan KB Pascapersalinan di Rumah Sakit , Makassar 31 Agustus 2010

Contraceptive choices for breastfeeding women .Journal of Family Planning and Reproductive Health Care 2004; 30(3): 181–189

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

• 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 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

• 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.

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

{Managing Contraception 2005-2007, page 92}

Teknik Pemasangan AKDR


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


Teknik Pemasangan AKDR


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.


Simplified Classification of Eligibility Criteria (WHO)

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

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. )

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

Emergency Neonatology&Obstetrics Care(EmNOC)

1. Parenteral antibiotics2. Parenteral oxytocics3. Parenteral anticonvulsants4. Manual removal of the placenta5. Removal of retained products6. Assisted or instrumental Vaginal Delivery7. Neonatal resuscitation8. Blood Transfusion9. Cesarean delivery1-7=EmNOC Basic (PONED)1-7+8&9=EmNOC Comprehensive (PONEK) UNFPA, WHO , 2000

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 users WFME 2004

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

• 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

Reducing Maternal and Neonatal Mortality in fiveDistrict 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

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% hospitalsinstitutionalized CEONC standards

Purpose of Intervention• Utilize CEONC through improving the competency of

practitioners

• Enable health centers & community midwives torecognize, stabilize, and refer emergency cases in a timely manner

• Create emergency communication and services network

• Build capacity of the DHO to lead and monitor thehospital-primary health care collaboration

• Assess the Improvement Collaborative effect in reducing MMR & NMR in hospital settings

Integrated CEONC ImplementationImplementing 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

Results on Standard of Inputs & Performance

Improved InputsInput Before After

Maternal 62% 90%

Neonatal 67% 90%

Improved Performance

Performance Before After

Maternal 67% 93%

Neonatal 62% 88%

Inputs: infrastructures, equipments, & manpower for providing CEONC

Performance: management of services, performance & quality improvement, and environtmental support for CEONC

Results on OutputReduced 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, 2004Midterm: March - August 2009 & Annual: March 2009 - February 2010

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

Prof biranroadtomaternaldeathpelatihan ponek jakarta290812

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