Indonesia makes maternal health a national priority : The Lancet

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The Lancet, Volume 380, Issue 9858, Pages 1981 - 1982, 8 December 2012

doi:10.1016/S0140-6736(12)62141-2

Indonesia makes maternal health a national priority

Paul C Webster Analysts have warned that Indonesia will not meet its Millennium Development Goal for maternal health. Can the country prove them wrong? Paul C Webster reports from Jakarta. When Indonesian President Susilo Bambang Yudhoyono visited London in late October, the Queen welcomed him with a 41-gun salute. The pomp matched the circumstances: in meetings with UK Prime Minister David Cameron and Liberian President Ellen Johnson Sirleaf over the next few days, Yudhoyono's task was to begin forging a new global development roadmap to replace the Millennium Development Goals (MDGs) when they expire in 2015. The three leaders are the co-chairs of the UN's High Level post-MDG panel charged with shaping whatever replaces the eight development goals that countries agreed to in 2000. Yudhoyono is a vocal international advocate for the MDGs. On his way home to Indonesia from London in early November, he stopped at an Asian-Europe summit in Laos to stress that full realisation of the MDGs was a sure way to build a better world. With the 2015 deadline looming, and progress lagging in many nations on goals such as reducing child and maternal mortality, Yudhoyono is turning up the heat, especially in Indonesia, where the lifetime risk of maternal death is one in 150 for women, as compared with one in 4000 in developed nations. Nobody hears Yudhoyono's calls more loudly than Indonesia's recently appointed director of maternal health, Gita Maya Koemara Sakti. It is her job to meet Indonesia's maternal health MDG by reducing mortality to 102 for every 100000 livebirthsone quarter of what they were in 1990. The President has asked us to meet 102. He's made it clear it's a national priority, she said in a recent interview at the Indonesian Ministry of Health headquarters in Jakarta. At the current rate of improvement we will be at 164 in 2015. But we can do better than that. Sakti's note of optimism would have seemed wildly unrealistic as recently as 2010, when efforts to reduce maternal mortality were, by all appearances, moribund. Indonesia, analysts at the UN warned that year, was not on track to achieve its maternal mortality target. The reasons, according to a World Bank investigation, were complex. According to many observers, an ambitious national midwifery programme created in the late 1980s that trained and placed 60000 midwives in rural villages and achieved rapid reductions in maternal mortality in the 1990s had faded in the face of apathy, greed, and corruption. Almost a quarter of births were unassisted by a doctor, nurse, or midwife, and many remote regions of the country reported intractably high numbers of deaths. Data from verbal autopsies in three districts indicated that high numbers of women were

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Indonesia makes maternal health a national priority : The Lancet

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dying during home births assisted by traditional birth attendants working alone without skilled help. While nearly 70% of Indonesia's wealthiest women gave birth with a health professional, only 10% of the poorest quintile did. Alongside this crisis in patient care, the national health system was being decentralised and many once-free public health servicesincluding maternal care in many placeswere privatised. 40% of Indonesian regional hospitals lacked obstetricians and lacked standard policies that would address the leading causes of death haemorrhage, infection, and eclampsia. Hospital patients encountered barriers including denial of service, demand for payment prior to service and inadequate treatment, the World Bank investigation reported. Echoing the UN, in 2010, Bappenas, the planning ministry that coordinates Indonesia's MDG efforts, warned that although the maternal mortality rate had fallen from 390 in 1991 to 228 in 2007, progress had slowed dramatically and hard work is needed to achieve the 2015 target. President Yudhoyono, says Sakti with a smile, heard that warning. After inviting Indonesia's 34 governors and his entire cabinet to a meeting on the MDGs in 2010, she explains, Yudhoyono issued a decree calling for a new national plan for accelerating the achievement of the MDGs. Action swiftly followed: new funding for health services in disadvantaged areas was earmarked andto the surprise of many who recalled that the government largely ignored a 2004 law promoting access to health carea 2009 law requiring the government to pay for all those earning less than $27 a month, or about 30% of Indonesia's 240 million citizens, has been implemented. The government is now energetically implementing a 2011 law stipulating that some of the decentralisation of the past decadea development that can be traced to a 1999 law shaped by austerityminded World Bank and International Monetary Fund advisers following the Asian financial crisis on the late 1990swill be reversed by 2014.

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Reuters/Cheryl Ravelo

Against this legal backdrop, Sakti explains, her ministry has adopted a four step plan that starts with bolstered family planning campaigns. The national social assistance system, known as Jampersal, has been expanded to provide free health care to all mothers regardless of their meansand regardless of whether they deliver their babies in private or public facilities. This will encourage large numbers of women to deliver their babies with help from trained assistance, Sakti insists. And we know that this will save large numbers of lives. We can save them by providing more midwives and strengthening basic emergency obstetrical and neonatal care.

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Sakti is also overhauling the national midwifery programme. Although this programme is credited with halving the maternal mortality rate between 1900 and 2000, as the government decentralised health care and devolved funding to the regions over the past decade, huge numbers of government-trained midwives started private practices and abandoned the villages. To reinvigorate maternal care in the villages where the largest number of mothers die, the ministry is offering cash incentives to encourage 72000 traditional birth attendants to work with midwives in the remote villages where they live. The government is also opening 2800 waiting homes where rural women can stay under supervision from midwives near medical clinics. Funding for 9000 health clinics has been increased sixfold over the past 2 years, Sakti says. More than 50% of maternal deaths occur in villages in the five provinces with the smallest health-care budgets and the most primitive conditions, Sakti explains. We're getting better data and we know where the deaths are occurring. Mien Ratminah, director of programming for the Indonesian Midwives Association, welcomes these reforms. But she warns that persuading rural women to give birth with trained attendants remains intractably difficult. Many rural women, she explains, see birthing as a natural process that family members can handle, perhaps with assistance from traditional village healers who will not refer women to medical facilities in emergencies. Ratminah, who served as director of maternal health for the densely populated province of West Java until 2006, also warns that government subsidies for midwives have spawned scores of substandard academies producing poorly trained midwives amidst numerous corruption charges. Licences for the academies are issued by the ministry of education, not the ministry of health, Ratminah adds. You can easily buy a licence and there really is no certification or inspection of the hundreds of new academies. At the Ministry of Health, Sakti candidly acknowledges Ratminah's concerns. The training for midwives was transferred from the health ministry to the education ministry and it's difficult to control, she complains. The academies have mushroomed and there are many questions about their competency. We've established a special board to tackle this question. Anne Hyre, director of a $55 million US Government-funded programme developed by the Johns Hopkins Program for International Education in Gynecology and Obstetrics (Jhpiego) to bolster training in 150 hospitals and 300 community health centres, argues that while the proliferation of inadequately trained midwives has become a serious impediment to reducing maternal mortality, the lack of emergency obstetrical care for women is equally serious. The majority of women are dying in facilities where clinical care is poor. There are not enough obstetricians, gynaecologists, and anaesthetists. And frankly, thanks to the education fiasco, there may be too many so-called midwives. Hyre's programme is funding efforts to bolster emergency care in partnership with the Budi Kemuliaan Hospital and Midwifery Academy in Jakarta, which is Indonesia's oldest maternity hospital. The hospital's director, Mohammad Baharuddin, is leading efforts to overhaul clinical care in five provinces by instituting clinical audits examining why women die in these facilities. These audits, he explains almost always identify the same culprits: a poor referral system to get help for women requiring emergency care, lack of trained personnel, poor hygiene in hospitals, and squandered financial resources.

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Baharuddin is not optimistic Indonesia will achieve its maternal mortality target, despite the President's decrees. We've broken the MDG promise, Baharuddin said on a tour of the spotless maternity ward in Budi Kemuliaan Hospital where scores of midwives tended to women and newborns. We're not on track. In the rural areas there is inadequate transportation available to get women to clinical facilities, and not enough trained personnel in the facilities. Even here in Jakarta, there are not enough hospital beds and not enough financial support for women facing catastrophic health costs. These are all issues the government is attempting to address, notes Untung Suseno Sutarjo, senior finance adviser to the Indonesian Ministry of Health. We began imposing standards last year for clinical conditions, and we are extending basic emergency obstetrical care, he explains. We are also considering paying transportation costs to get women in rural areas to health services. We know they can't reach the services because they don't have money. But we also know many women consider delivering their babies outside of their homes to be bad luck.

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Paul C Webster

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