Accelerating improvement in maternal health : why reform is needed

August 2010 Policy and Discussion Notes 59472 Indonesia Health Sector Review Accelerating Improvement in Maternal Health: Why reform is needed Introduction1 At least 10,000 women continue to die of childbirth-related causes every year in Indonesia. Even with the most recent estimate of 229 maternal deaths per 100,000 live births (Lancet 20102), Indonesia's MMR remains among the highest in East Asia. At the same time, past efforts are not to be minimized (Figure 1): in the five years prior to the 2007 IDHS survey, more than 73 percent of births were attended by a professional health provider (doctor, nurse, or midwife) and facility-based deliveries increased to 47 percent, with over 90 percent of the recent increase due to the use of private sector facilities. Cesarean section rates, an important measure of comprehensiveness of care, increased from 0.8 percent in 1986-89 to 6.8 percent in 2003-07, again mostly provided in private sector facilities. Main Challenges relied only on traditional birth attendants to deliver, were referred too late and even when referred did not Inequities between rich and poor women and those get appropriate treatment (Figure 2, World Bank 20104). living in rural and urban areas generally decreased with the increased use of professional health In addition, although prenatal and postnatal care providers3 for deliveries. Yet the richest are still seven increased to high levels, use of family planning times more likely to access a facility than their poorest services has stagnated. There are persistent high counterparts. Hence, a large number of poor women rates of unintended pregnancies among both married continue to give birth at home without professional and unmarried women. Recent reviews of the national help. A review of a sample of maternal death audits family planning program highlight the need to address from West Java (n=210) in 2009 reveals a large share contraceptive practices among high-risk groups, of women who died due to childbirth-related causes especially the growing group of unmarried women  Figure 1: Trends in MMR, Skilled Birth Attendance and Facility-based Delivery in Indonesia (1990-2007) 500 80 Maternal Death per 100.000 Live Birth 70 400 390 60 334 300 307 50 percentage 40 73,9 228 200 66,3 30 43,2 47,2 39,8 39,8 20 100 102 17,5 20,7 10 Targ et MDG 5 by 2015 - 0 1990-1994 1993-1997 1998-2002 2003-2007 2015 Year Skilled birth attendant Facility based delivery Maternal Mortality Ratio Source : IDHS 1994-2007 The latest Lancet series shows MMR Indonesia 229 Figure 2: Snapshot of Verbal Autopsies No Name Age Preg. ANC Time of Cause of Provider Procedure Baby Note History death death First Second Third Fourth status 1 Ne 29 G2P1A0 6 30 minute Other causes Private Vacuum Stillbirth post partum hospital Extraction 2 Tt 28 G4P3A0 3 1 day post Eclampsia Midwife District SC Well partum hospital 3 En 23 G3P2A0 2 8 hour post Post partum TBA Midwife District Well partum bleeding hospital 4 Asr 36 G3P2A0 3 2 hour post Undiagnosed TBA Well partum (twin) 5 Fat 25 G3P2A0 3 4 hour post Post partum TBA Midwife Puskesmas Well Midwife not available, partum bleeding died on the way to district hospital 6 Ph 20 G1P0A0 1 40 week Eclampsia Puskesmas Private Maternity IUFD pregnancy hospital hospital 7 Rd 21 G1P0A0 3 9 day post Other causes Midwife Well Midwife recommended partum referral, patient did not go 8 Ih 30 G3P2A0 6 4 hour post Post partum TBA Midwife District Well Ob-gyn cannot be partum bleeding hospital contacted at district hospital 9 IS 27 G2P1A0 5 12 hour post Post partum Private SC Well partum bleeding hospital 10 Ul 16 G1P0A0 2 6 week Dehydration District IUFD pregnancy hospital 11 Mam 22 G1P0A0 3 6 day post Eclampsia District SC Well partum (post SC) hospital (twins) 12 A 42 G7P6A0 6 3 hour post Eclampsia, TBA Midwife Private Vac Extr Well partum bleeding hospital 13 Nan 42 ? ? 2 hour post Post partum Stillbirth No assistance during partum bleeding delivery 14 Suh 27 G1P0A0 3 33 hour post Pre-eclampsia Midwife Private District Private SC Stillbirth Rejected at first - 2 partum hospital hospital hosp hospitals because first hospital was full 15 Id 2 35 G3P2A0 3 3 hour post Post partum TBA Midwife Puskesmas Well partum bleeding 16 ES 20 G1P0A0 9 28 day post Other causes Midwife Well Died in hospital partum Source: World Bank (2010). 2 Indonesia Health Sector Review who are sexually active and whose needs are ignored know about their eligibility for Jamkesmas coverage; by family planning programs. Unintended pregnancies they do not understand the benefits and remain unsure among the 24 million women in this group are more about the possible future costs of delivery at a facility. likely to result in unsafe abortion and lead to more They often refuse referral of obstetric complication to a maternal deaths. Although little information is facility due to transport costs which are not included in available about the incidence of abortion, estimates the benefit package (Figure 3). range between 700,000 and 3 million abortions each year, many of them performed in unsafe conditions In the case of referral for women with obstetric with increased risks (Hull et al 2009)5. Family planning complication, the quality of the emergency obstetric service delivery has shifted to the private sector over care is poor and still often results in unnecessary the last decade, with the subsequent risk that the poor deaths. Village midwives do not always stabilize the may face financial barriers in accessing these services. cases before referral; health centers that provide Basic Privatization without regulation has also meant a shift Emergency Obstetric and Newborn Care (BEONC) towards more temporary and profitable contraceptive are often bypassed because of the perceived lack of methods, as seen with the shift towards short-term ability to handle complications, while not all districts injectables as the primary contraceptive nationally. have a functioning hospital with Comprehensive Emergency Obstetric and Newborn Care (CEONC). The high cost of, and uncertainty about, medical Despite attention in past years and policies to promote expenses continue to discourage women from facilities that are able to treat obstetric emergencies, seeking care when needed. In order to provide few areas have reached UN standards and few facilities better financial protection against catastrophic health fulfill the required CEONC criteria, leaving women at expenditures and to increase access to care, the GoI risk of inadequate treatment once they are referred in 2005 introduced the Health Insurance for the Poor to a facility. Quality concerns apply to both public and Program Askeskin