BACKGROUND

Health development in Gorontalo Province has contributed greatly to the achievement of

public health status. One of the indicators can be seen from Human Development Index
(IPM) Gorontalo Province in 2013 which is 71.77, this achievement is an increase from the
year 2012 that is 71.31. Achievement of HDI is not separated from the participation of
government, across sectors in planning and implementing health programs, especially for
maternal and child health, community nutrition improvement and other strategic programs
in the field of health. Efforts to improve the health status of the community continue to be
implemented and evaluated, especially the achievement of maternal mortality (MMR) that
has not met the target, Infant Mortality Rate (AKB), Underfive Mortality Rate (AKABA) and
nutritional status of society which is a performance indicator to keep decreasing from year
To year.
The people of Gorontalo are part of 55% of the world community living 85 km from the
coastline. Coastal and marine areas for their own significance for the Province of Gorontalo.
One of the coastal areas in Gorontalo Province is North Gorontalo Regency. North Gorontalo
District is a district administrative area which is carved out of the district of Gorontalo,
Gorontalo province enacted through Act No. 11 of 2007 on the Establishment of North
Gorontalo District.
Geographically, more than 75 percent of North Gorontalo Regency is a coastal region,
with a long coastline of 320 square kilometers (km 2),
while the longest coastline in the
province of Gorontalo facing the Pacific Ocean. The total area of Gorontalo Utara is 1,777.3
square kilometers, covering 6 districts and 56 villages in 2010 and in 2011 to 11 subdistricts
and 123 villages, including the widest area of Kecamatan Atinggola, covering 264.55 square
kilometers and Kecamatan the smallest breadth of the District Ponelo namely Islands 10.40
Km 2.

Ponelo Islands Sub-district is the newest district in North Gorontalo regency and is
located on the north coast of Sulawesi island. Subdistrict Ponelo Islands is the result of
pemekaran from Kwandang sub-district. This district position is located in the archipelago
with the least number of villages among the other districts in Kabupaten Gorontalo Utara.
Although in Ponelo Islands there are only 4 villages but this area has most small islands that
is about 14 islands. The Area of the District Ponelo Islands is 7.89 km.
Based on data in Ponelo Island sub-district administration, the population of Ponelo
Islands sub-district in 2015 is 4,100 people consisting of 2051 male and 2049 female
residents. By 2015 the population density in the Ponelo islands is 558 people per square
meter. The largest number of people in Ponelo village is 1.211 or about 30 percent of the
total population in this kecamatan. And otiola village is the village with the smallest
population, where the village is only inhabited 805 inhabitants. Furthermore, by 2015 there
are 1072 heads of households in this kecamatan with an average of 4 families each.
Maternal and child health is one of the crucial issues in the achievement of development
around the world. Maternal and child health services not only sensitively reflect the
development of a country, but also as an investment for improving the quality of human
resources in the future. A healthy mother and child is essential to achieving a healthy
generation and a strong nation.
Maternal and Child health efforts are efforts in the health sector concerning the care and
maintenance of pregnant women, mothers, nursing mothers, infants and toddlers and
preschoolers. Community Empowerment in the field of MCH community in order to
overcome the emergency situation from non-clinical aspects related to pregnancy and
childbirth. The preparedness system is a helpful-aid system, established from, by and for
the community, in the use of transport or communications equipment (mobile phones,
landline), funding, blood donors, monitoring and information monitoring. In this sense,
health education for the community, community leaders and the skill of baby shamans and
health counseling in kindergarten are also included.
The aim of the Mother and Child Health Program (KIA) is the achievement of healthy
living ability through the optimum level of health improvement for mother and her family to
reach the Norma Keluarga Kecil Bahagia Sejahtera (NKKBS) and the increasing of child
health to ensure optimal growth process which is the foundation for Improvement of human
quality completely.
The Report on the Achievement of the Millennium Development Agenda shows Indonesia
achieves uneven progress among indicators: achieved for specific targets, lagging behind
other targets. Underfive Mortality and Infant Mortality, for example, has declined sharply but
is not expected to reach the MDGs target in 2015. Meanwhile, Indicator Reduced Mortality
Rate and measles immunization in infants and children 6-59 months have met the MDGs
targets. (Bappenas, 2013)
Disparities in health status also occur between socio-economic, inter-regional and inter-
urban-rural levels. The infant mortality rate and under-five mortality rate among the poorest
are almost four times higher than the richest. In addition, infant mortality and maternal
mortality rates are higher in rural areas, in eastern Indonesia, as well as in low-education
populations. Percentage of children who lack and poor nutritional status in rural areas was
higher than urban areas (Ministry of Health Year Strategic Plan 2015-2019). Thus, for
Indonesia, health has become an unfinished homework. The emphasis on health as a key
element of sustainable development was returned to its momentum by becoming the third
goal the Post-2015 Development Agenda: "Ensure healthy lives and promote wellbeing for
all at all ages".
The success of maternal health efforts, among others can be seen from the indicator of
Maternal Mortality Rate (MMR). MMR is the number of maternal deaths during pregnancy,
childbirth and childbirth caused by pregnancy, childbirth, and childbirth or management but
not for other causes such as accidents, falls, etc. in every 100,000 live births. This indicator
is not only able to assess the maternal health program, moreover able to assess the degree
of public health, because of its sensitivity to the improvement of health services, both in
terms of accessibility and quality.
Based on the Indonesian Demographic and Health Survey (SDKI), Indonesia's maternal
mortality rate decreased from 390 per 1000 live births (SDKI, 1994) to 228 (IDHS, 2007).
Nevertheless, the IDHS data for 2012 shows a significant increase in MMR to 359 maternal
deaths per 100,000 live births. The findings of this statistic is an anomaly because of
Indonesia declare the proportion of births attended by skilled health personnel increased
from 40.70% (1992) to 83.10% (2012) as a result of the village midwife program by
government since 1990. In 2015, AKI Showed a decline to 305 maternal deaths per 100,000
live births based on the results of the Intercensal Population Survey (SUPAS) 2015.
Maternal mortality rate in Gorontalo Province decreased by 2014 from 252 deaths per
100,000 live births to 195 (Profile of Gorontalo Provincial Health Office 2015). But again
showed a consecutive increase in the last two years of 253 deaths per 100,000 live births in
2015 and 301.7 deaths per 100,000 live births in 2016 (Profile Dinkes Gorontalo, 2016).
Meanwhile, for Kabupaten Gorontalo Utara there are 4 cases of maternal mortality from
2,119 live births in 2015.
Efforts to decrease MMR means improving health services for mothers and children
including antenatal / Ante Natal Care (ANC), which is health care by professionals
(obstetricians, general practitioners, midwives, auxiliary midwives and nurse midwives) to
the mother during pregnancy, according With a minimum standard of antenatal care that
includes 5T weighing, measuring height, measuring blood pressure, giving TT immunization,
measuring fundus height of uterus and giving iron tablets of at least 90 tablets during
pregnancy.
Maternal care coverage seen from first visit (K1) and fourth visit (K4). Based on health
data data of Gorontalo Regency / City in 2015, the highest coverage of K1 in Gorontalo
Province is in Kabupaten Gorontalo Utara with 104.6% while lowest K1 coverage is in Bone
Bolango Regency with 93.7%. For the highest K4 coverage in Gorontalo Province in 2015 is
located in Gorontalo City with 94.9% and the lowest in Kabupaten Gorontalo Utara with
75.7%.
The number of pregnant women in Kabupaten Gorontalo Utara in 2105 ie 2341 pregnant
women. However, only 1772 pregnant women who visited K4. As it is known, the higher the
K4, the better the quality of ANC service and the participation rate of pregnant women to
the health worker.
Maternal health efforts are carried out in order to encourage every deliveries to be
assisted by trained health personnel and undertaken in health care facilities. The
achievement of maternal health efforts is measured through indicator of percentage of
deliveries assisted by trained health personnel. (SDKI, 2012).
The percentage of deliveries delivered by health personnel in Indonesia shows an
increasing trend from 2005 to 2015. However, there is a decrease from 90.88% in 2013 to
88.55% by 2015. The Ministry of Health's policy in the last decade emphasizes that every
delivery is helped by health personnel in order to reduce maternal mortality and infant
mortality. However, although delivery is attended by health personnel but not implemented
in health care facilities, it is considered to be one of the causes of the still high maternal
mortality rate. Therefore, starting in 2015, the safe suppression of childbirth is deliveries
assisted by health workers at health-care facilities. Therefore, the Ministry of Health's
Strategic Plan 2015-2019 establishes delivery at health-care facilities as an indicator of
maternal health efforts, replacing delivery assistance by health personnel.
For Gorontalo Province, the number of births has not reached 100,000 live births, but in
order to measure the performance of the health sector at the regional level based on the
Local Government Medium-Term Plan (RPJMD) and the Strategic Plan (Renstra) of
Gorontalo Provincial Health Office through the commitment between the Head Regions in
this case the Governor, Vice Governor and the Health Service Unit then to see the success
of the maternal health program is calculated by using the number and maternal mortality
rate.
Referring to the Strategic Plan of the Ministry of Health 2015-2019 which sets AKI's
target at 306, then the target of the 70/005 Life Development Agenda in 2030 and no more
than 140 for any country becomes very ambitious. Thus, the issue of increasing the
coverage of labor that is not followed by improvements in the quality of services should be
addressed immediately. Implementation of policy directions around (1) Strengthening
primary health care, (2) Implementing a continuum of care approach, and (3) and health-
based risk interventions. Maternal health factors during pregnancy and childbirth, will be
closely related to neonatal mortality, infant mortality rate, and toddlers.
 The cross-sectoral approach becomes a valuable lesson from the implementation of the
MDGs and the process of preparing the Post-2015 Development Agenda. Indonesia has
proven that health issues require multi-sectoral and multi-level governance approaches.
Amid improvements in the availability of health personnel and facilities, for example,
problems surrounding access roads to health care facilities, the absence of clean water
sources and low maternal knowledge of pregnancy and childbirth significantly contributes to
the high maternal mortality rate. Without significant improvements in development
indicators outside the health sector, such as education, infrastructure and the environment,
"health for all" will be difficult to achieve.
Maternal health problems are a cross-cutting problem so the settlement requires
cooperation from various parties, in this case not only the health workers, but also the
government, the family and the community. The existence of limited information in some
areas causes the high public interest towards myths and beliefs in shamans rather than
birth attendants (midwives, doctors). P olicy governments are not partial to the neediest also
become a factor causes of maternal mortality. Pregnant women and women in general often
do not get benefit from programs that are actually addressed to them.
The cause of maternal mortality in general in Indonesia and especially in Gorontalo is
due to bleeding caused by delays in obstetric obstetric care (25.6%) (Health Profile of
2014). In addition there are other factors such as factors of health personnel, low maternal
knowledge related to pregnancy and the problems that accompany, and low public
awareness about the health of pregnant women who are determinants of mortality.
Health facilities in Gorontalo Utara District include Hospitals, Posyandu, Puskesmas and
Polindes. For North Gorontalo Hospital only has 1 public hospital, while for Puskesmas
spread in every District. Medical personnel serving the people in Kabupaten Gorontalo Utara
are 23 doctors, 139 nurses, 64 midwives and 19 pharmacists.
The ratio of health personnel to the population is an indicator to measure the availability
of health personnel to achieve certain health development targets. Based on the Decree of
the Coordinating Minister for People's Welfare No. 54 of 2013 on Health Workforce
Development Plan for 2011-2025, the target ratio of health workers to population by 2019
is the ratio of general practitioners 45 per 100,000 population, the ratio of dentists 13 per
100,000 population, Nurses 180 per 100,000 population, and the ratio of midwives 120 per
100,000 population. The ratio of midwives in Indonesia in 2015 amounted to 43.74 per
100,000 population. This figure is still far from the 2019 target of 120 per 100,000
population and also has not reached the previous year target of 100 per 100,000
population. By 2015 the ratio of medical personnel per 100,000 population in Gorontalo
Province is doctors 21,97, dentist 3,88, nurses 95,83 and midwife 63,98. This of course still
does not meet the national target that has been set.
The need for health personnel is based on the Minimum Human Resources Standard of
Human Resources (SDMK) Puskesmas based on Regulation of the Minister of Health
(Permenkes) number 75 year 2014 on Puskesmas. Where mentioned the minimum doctors
are expected to be in Puskesmas in order to carry out health services with either Puskesmas
Rawat Inap has at least 2 doctors, while the standard of Puskesmas Non Rawat Inap at least
1 doctor. Similarly, the standard for midwife staff at the Puskesmas is one Puskesmas Rawat
Inap has at least 7 midwives, while Puskesmas Non Rawat Inap has at least 4 midwives. The
standard for midwives does not include the staff at the Puskesmas Pembantu and Bidan
Desa, of course, at the Puskesmas Pembantu and the Village Midwife at least have 1
midwife each.
In general, health workers in Gorontalo Province are still below the standard target that
is feasible to meet one area to serve the needs of public health. Nevertheless, the
government has been trying to fulfill these energy needs to remote areas and islands by
implementing health personnel capacity building program through the procurement of
doctors and PTT midwives who will be distributed to remote and very remote areas
throughout Kabupaten / Kota.Tetapi problems of distribution of employees and PTT Is still
less effective, while the need for personnel, especially doctors and specialist doctors in the
District / City has not been met so it still requires efforts to the implementation of rewards
and punishment from the government to put existing health workers in accordance with
needs.
The existing health facilities in the District Ponelo Islands are Puskesmas, Poskesdes and
Polindes each of which amounted to one fruit. Health facilities that certainly need to be
supported by the presence of adequate health workers as well. The health workers in Ponelo
district consist of 1 doctor, 2 nurses and 6 midwives. The active participation of the
community in supporting health is seen by the presence of 3 trained TBAs in this
kecamatan. The number of medical personnel is still quite low considering the number of
residents in the Ponelo Islands district that is 4100 inhabitants.
Throughout the year 2015, there are 9 types of toddler immunization conducted in
Ponelo Islands District. Of the 99 infants in Ponelo Islands sub-district, 11 of them received
polio immunization 1, 9 toddlers received BCG immunization, 8 toddlers received polio 3
immunization and there were 3 children who received measles immunization.
By 2015 there are 59 infant deaths per 1000 live births in Kabupaten Gorontalo Utara.
This number is slightly decreased compared to 2014 ie 63 infant deaths. Meanwhile, data
show that of the 2,115 babies born alive in 2015, 129 infants (6.1%) experienced LBW. This
is not apart from one of the factors LBW namely the condition of the mother during
pregnancy. It is known that there are pregnant women who suffer from Chronic Energy Less
than 331 of 2341 registered pregnant women.
The distance of the Ponelo Islands district is only about seven kilometers from
Kwandang, the capital of the northern district of Gorontalo. Nevertheless, the only access to
reach the outer islands facing the Pacific Ocean is only by using a machine boat for half an
hour. If the water receded, the boat could not dock perfectly. Residents must walk on
shallow water for almost a kilometer from the shore. Natural factors that also make Ponelo
residents a little isolated. Economic access for local residents who mostly work as fishermen
and farmers was hampered. The limited access and constraints of this facility can be one of
the risk factors in improving maternal and child health.