INTERNATIONAL CONFERENCE ON CSR AND COMBATING MALNUTRITION: OBTAINING MILLENNIUM DEVELOPMENT GOALS (MDGs) IN INDONESIA

Session 1: Prevention & Intervention in Improving The National Nutrition Status in Indonesia Budi Iman Santoso, Sp. O.G., Head of Obstetrics & Gynecology, Cipto Mangunkusumo Hospital
Grand Sahid Jaya Hotel, 13 14 December 2010

EFFORTS OF OBSTETRIC CARE ON REDUCING MATERNAL MORTALITY RATE TO ACHIEVE MDG TARGETS IN INDONESIA

Dr. Budi Iman Santoso, SpOG(K) DEPARTMENT OF OBSTETRIC-GYNECOLOGY CIPTO MANGUNKUSUMO HOSPITAL FACULTY OF MEDICINE UNIVERSITY OF INDONESIA JAKARTA

OUTLINE
Introduction Achievement of Reduced MMR Comprehensive analysis

Linear and Dynamic System Priority Strategy 5W + 1 H

Role of Obstetric Care SWOT Analysis Conclusion

INTRODUCTION
Millenium Development Goals (MDGs) September, 2000 the Millenium Summit of 189 UN Nations, the Millenium Declaration Indonesia:

The National Long-term Development Plan RPJPN (2005-2025) Mid-term: RPJMN 2005-2009 & 2010-2014 Annual: RKP

INTRODUCTION MDGs

Pro-growth, pro-jobs, pro-poor and pro-environment 8 targets: 5A. Reduce MMR by three-quarters between 1990-2015 5B. Achieve universal access to reproductive health

THE CURRENT STATUS OF MDG TARGETS

3 categories of MDG achievement A. Have already been achieved: 1,3,6 B. Significant progress has been achieved: 1, 2, 3, 4, 8 C. Still requires great efforts to be achieved: 1,5,6,7

REDUCED MATERNAL MORTALITY RATE IN INDONESIA

1992: 425/100.000 2007: 228/100.000 RJMPN 2014: 118 MDG 2015: 102 Acceleration initiatives! Global: MDG 5 slow progress

Only China and Vietnam have been on track Separating MDG 5A and 5B (introduced 2007)

Indicators of Achievement: MDG 5

Mostly, still

need special

attention Indonesia: We are not alone similar results in Asia Pacific region

COMPREHENSIVE ANALYSIS

LINEAR SYSTEM OF THINKING DYNAMIC SYSTEM PRIORITY STRATEGY 5 W + 1 H

LINEAR SYSTEM : Gender, Nutrition, Safe Abortion

Pre-Pregnancy, Pregnancy, Labor & Delivery, Post-Partum

Gender Issues- Reproductive Health: Womans Basic Human Rights

Safe mother Safe child

Mothers nutrition - neglected

Dear man, Do you really care for your woman & children??

Family Planning Safe Abortion, Womans right

Womans right is not only in Education and Work But most importantly is the right to decide whats best for her body

DYNAMIC SYSTEM :

4 sub-systems:
Demography, social and culture (blue) Family Planning (yellow) Quality of labor assistance (red) Environment and sanitation (grey)

PRIORITY STRATEGY 5W +1H

WHAT 4 Priority Strategies, 1 Vision: Making Pregnancy Safer

Quality of Effective Health Services Inter-program/sector/private partnership Family empowerment Public Mobilization

WHERE Extreme extensive area in Indonesia Map of Priority for Target Area

PRIORITY STRATEGY 5W +1H

WHO

Target: mother and couples of reproductive age Executor: Health care professionals

Mutual responsibilities: government, private & community Need a Consultant Manager? Role of general practitioner in assisting labor (in service & pre-service)

WHEN tight deadline 2015

PRIORITY STRATEGY 5W +1H

When is the best time for monitoring & evaluation Improvement on indicator Official / Alternative indicator

WHY clearly stated in linear & dynamic system HOW Start the Effective Strategy ASAP

Guidelines Meetings & panel discussion

Official or Alternative indicators?

Asian-Pacific Resource &Research for Woman (ARROW)

THE ROLE OF OBSTETRIC CARE

Most maternal death is due to obstetric complication and emergency Risk of maternal death extremely high: 100 x on First day after labor 30 x on Second day postpartum 14.8% - 1 week before labor 43.5% during labor 23.7% in 1 week after labor

Obstetric care has important role on Strategy 1 (Access and Quality Health Services)

Obstetric and neonatal emergency care Preventive and promotive care:

Pre-pregnancy (Family Planning, Pre-marital counseling, Improved Nutrition, Immunization) During pregnancy (ANC, BPCR, Fe, Calcium (PE/E), Immunization) During Labor (Labor assistance in Health Care Facility, Safe and Clean Labor, CTG, Biophysical profile, Partograf, MAK III, Initial breast feeding)

ROLE OF OBSTETRIC CARE

JNPK (Jaringan Nasional Pelatihan Klinik) & MOH Directorate General of Medical Services have conducted training on Comprehensive Emergency Obstetrics and Neonatal Care (CEONC) at Tangerang Hospital (20082009)

Training Results
20 hospital staff (3 obs-gyn, 2 pediatricians, 9 midwives, 6 nurses) are certified in CEONC 4 Health Care units are certified in BEONC 40 midwives are certified in LSS

Training results

Midterm Maternal Death reduced from 32/2998 to 12/3503 live-birth Annual Maternal Death reduced from 52/5002 (2008) to 29/7018 live-birth (2009).

Reduced Annual Mortality*

Mortality
Maternal per 100,000 live-births
Perinatal per 1000 live-births

2008

2009

800
30

300
16

Effective Obstetric Care Cause of death Bleeding Infection Eclampsia Delayed labor Effective care AMTSL,Obstetric transfusion % reduction care, 40%

Preventing infection and 13% uses of antibiotics Magnesium Sulfate & anti 7% hypertension agents Partograf, competence Operator 10%

ROLE OF OBSTETRIC CARE

Health care professionals have less role in Strategy 2 (Inter-Program & Sector Partnership) Rigid bureaucracy & regulation Turniani L, et al: Strategic policy has supported the program of reducing MMR Sugeng et al: not all sectors have realized the importance of program to reduce MMR

Program supported by local government policy Province East Java Supported Program APN, PONEK, AMP, PONED, CAPACITY BUILD GSI, AMP, Bidan Siaga, MPS GSI, SPM, AMP

South Kalimantan
North Sulawesi

ROLE OF OBSTETRIC CARE

Least role in Strategy 3 (Family Empowerment) In Strategy 4 (Public Mobilization) it depends on government initiatives to involve the health care professionals

COULD WE ACHIEVE MDG 5 BY 2015??

SWOT analysis ON MDG 5 - 102/100,000 livebirth on 2015 STRENGTH Fine human resource Good strategy program High commitment by private sectors (CSR) the Weakness Different vision, not well-coordinated Less concern on priority government, Less awareness on reproductive health Geographical obstacles Tight deadline needs Problems in training of labor assistance Threat womans right in

Overseas fund: USAID for CEONC Many programs have been conducted Positive reduction acceleration Opportunity on MMR,

Support by developed countries on MDG No concern on existing program program Egoism fond of new program rather than integrating with the existing program

CONCLUSION

Positive reduction in MMR needs acceleration Issues on discussion:

Gender equality / womans right: family planning, nutrition, safe abortion Alternative indicators Effective Strategy Consultant manager Using technology : www. kesehatan-ibuanak.net Launching: 30 Nov 2010 Training of labor assitance (in service dan pre-service) Fund rising

GREATEST THREAT: WE DONT CARE

I dont care

REDUCING MMR = Treating Wound Healing

At beginning Everything looks terrible. But We Care !!

(On courtesy of: Kompyang Rata, I Gusti Agung)

First month After exhausting efforts of daily care.. Nearly loss of hope But.. We do care!!!

Third month. On Progress.. For the patient, it is still troublesome But.. We still and do care !!

Fourth month and there is a smile 120 x weve tried to be still and do care..

When it seems nothing Actually, there is everything

Every dark cloud has a silver lining

Is it a road to DIE or to SMILE We decide..