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.
Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011
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
Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011
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
Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010
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 %
Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010
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
Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010
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
Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010
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
Teknik Pemasangan AKDR
Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010
Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010
Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010
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
Simplified Classification of Eligibility Criteria (WHO)
Affandi B. Perkembangan Kontrasepsi, Teknik Penapisan dan KB Postpartum , BPMPPKB, Balikpapan , 24 Juni 2010
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
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
Ronsmans et al. Bulletin WHO 2009;87:416-423
Ronsmans et al. Bulletin WHO 2009;87:416-423
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
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