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SAMPLE REGISTRATION SYSTEM

2014

CENTER FOR COMMUNITY EMPOWERMENT, HEALTH POLICY AND HUMANITIES

NATIONAL INSTITUTE OF HEALTH RESEARCH & DEVELOPMENT

MINISTRY OF HEALTH REPUBLIC OF INDONESIA

2015

INDONESIA

Indonesian SRS 2014 i

Indonesia:

Sample Registration System 2014

Indonesian SRS 2014 ii

NIHRD Library Cataloguing in Publication Data

Indonesia: Sample Registration System 2014

1. Indonesia 2. Health outcome indicators 3. Millennium Development Goals

4. Causes of death

The National Institute of Health Research and Development 2015

29 Jalan Percetakan Negara

Jakarta 10560

INDONESIA

Internet: www.Litbang.kemkes.go.id

E-mail: [email protected]

All rights reserved

ISBN

http://www.litbang.kemkes.go.id/

MINISTER OF HEALTHREPUBLIC OF INDONESIA

FOREWORD

Millennium Development Goals with health related goals (no. 4,5and 6) will end in 2015. All countries, including lndonesia, whichsigned the MDGs in 2000 have to report their achievements.

ln order to obtain outcome indicators and causes of death, theNational lnstitute of Health Research and Development - Ministryof Health Republic of lndonesia in collaboration with theDirectorate General of Population and Civil Registry - Ministry ofHome Affairs and local governments in 30 provinces, 119

districts and cities that represent lndonesia, has initiated Sample RegistrationSystem that collected mortality data from the households with death events fromJanuary to December 2014.

The results show the "real-time" health outcome indicators representative forlndonesia and describe the achievements of MDG 4, 5 and 6 in2AM.Besides, the results will guide the public awareness on the selection of priority healthprograms and provide input for appropriate allocation of health resources in thehealth sector, as well as accelerate the efforts to achieve the national healthdevelopment objectives.

On this occasion, I would like to congratulate and express my highest appreciation tolocal government officials (province, district, city, subdistrict, village), NIHRD

researchers, officials from provincial, district and city Health Offices; physicians and

paramedics of community health center (PUSKESMAS) as well as all parties

involved in this activity.

Hopefully, the findings will contribute to national efforts in improving the health and

welfare of the lndonesian people.

tu,Prof. Dr. dr. Nila Farid Moeloek, Sp. M(K)

Minister of Health of the Republic of lndonesia

tndonesian sRS 2orn E

H.R. Rasuna Said Street Block X5, Kav. 4-9 Jakarta 12950 PhonelFax (+6221) 5201591

Indonesian SRS 2014 iv

PREFACE

Real-Time Health Outcome Indicators to evaluate national achievement of Millennium

Development Goals 4, 5 and 6 are needed to be used as milestones for National Health

Development Programs.

In order to assess accurately, the Center for Community Empowerment, Health Policy and

Humanities – the National Institute of Health Research and Development, Ministry of Health

Republic of Indonesia has implemented the 2014 Sample Registration System with the objective

of collecting births, deaths and causes of death in the sample area that includes 128

subdistricts, 119 districts and cities; located in 30 provinces in all over Indonesia.

This report presents results of the 2014 Sample Registration System and the key findings as well

as the policy implications.

The findings consist of health outcome indicators for 2014 (real time, with adjustment) and

Underlying Causes of Mortality based on International Statistical Classification of Diseases and

Related Health Problems, Tenth Revision, World Health Organization (1992); using life cycle

approach as stated in the Indonesian Medium Term Health Development Plan 2015 - 2019

Hopefully this activity will contribute to the sustainable efforts to improve health programs in

Indonesia and in designing more effective interventions to control priority diseases.

Soewarta Kosen

Principal Investigator and Editor

Indonesian SRS 2014 v

ACKNOWLEDGEMENTS

The 2014 Indonesian Sample Registration System was successfully completed due to the efforts

and involvement of various public institutions and community organizations at various levels

and at different stages of the activities.

Herewith, we would like to thank everyone who helped making the efforts a success. First of all,

we are grateful to the Ministry of Home Affairs and local governments in all over Indonesia, for

its leadership and continuous support. We would also like to express our thanks to the Badan

Pusat Statistik (BPS)/Statistics Indonesia for providing guidance and support in the sample

design and selection of samples (subdistricts), using 2008 Village Potency Survey data.

At the NIHRD, we express our gratitude to Prof. Tjandra Yoga Aditama, M.D., (Pulmonologist).,

MARS., DTM&H, DTCE., the Head of the National Institute of Health Research & Development

and to all Researchers under the leadership of . Soewarta Kosen, who coordinated the tasks

related to SRS, preparation, planning, implementation, data analysis and report writing.

We would also like to express our thanks to the Ministry of Home Affairs and Provincial, City

and District Governments in the sample area for their administrative support and collaboration.

We are also sincerely grateful to the GLOBAL FUND – Cross Cutting Health Systems

Strengthening Intervention 2012 – 2014, for their administrative support and financial

assistance in conducting the Indonesian SRS.

This acknowledgement would not be complete without expressing appreciation for the hard

work showed by the interviewers, supervisors, and IT personnel involved in collecting and

processing the SRS; as well as by the administrative staff at the NIHRD. Finally, we appreciate

the informants and family members of the decease who were willingly respond to the detailed

questions with patience and without any expectation.

Indonesian SRS 2014 vi

Agus Suprapto, DDS., M.Kes.

Director, Center for Community Empowerment, Health Policy and Humanities

National Institute of Health Research & Development

Ministry of Health Republic of Indonesia

Indonesian SRS 2014 vii

CONTRIBUTORS

Soewarta Kosen

Ingan Ukur Tarigan

Tita Rosita

Endang Indriasih

Yuslely Usman

Tati Suryati

Endah Dwi Pratiwi

Retno Widyastuti

Idawati Muas

Merry Lusiana

Pramita Andarwati

Tety Rachmawati

Tri Juni Angkasawati

Riswati

Ni’matun Nurlaela

Meda Permana

Irfan Ardani

Indah Pawitaningtyas

Ria Yudha Permata

Linda Nilawati

Tuty Alawijah

Sugito Ariyana

Firda Oktaviani

Risna

Indonesian SRS 2014 viii

CONTENTS

Contents Page

Foreword…………………………………………………………………………………………………………...

iii

Preface……………………………………………………………………………………………………………...

iv

Acknowledgements………………………………………………………………………………………..….

v

Contributors………………………………………………………………………………………………………

vii

Contents……………………………………………………………………………………………………………

viii

List of Tables……………………………………………………………………………………………………..

x

List of Figures…………………………………………………………………………………………………….

xii

Executive Summary…………………………………………………………………………………………… Xiii

1 Background……………………………………………………………………………………… 1

2 Objectives……………………………………………………………………………………….. 4

2.1 Specific Objectives……………………………………………………………………………. 4

3 Strategies…………………………………………………………………………………………. 5

3.1 Strategies that were applied include………………………………………………… 5

3.2 Verification of Completeness were carried out using several methods……………………………………………………………………………………………

5

4 Methods…………………………………………………………………………………………. 6

4.1 Selection of National Representative SRS Sites…………………………………. 6

4.2 Report Mechanism of Death Event…………………………………………………. 8

4.3 Organization of SRS…………………………………………………………………………. 8

5 Results……………………………………………………………………………………………. 9

Indonesian SRS 2014 ix

5.1 Health Outcome Indicators……………………………………………………………... 10

6 Conclusions………………………………..…………………………………………………… 34

References……………………………………………………………………………………………………….. 38

Annex 1……………………………………………………………………………………………………………. 39

Annex 2……………………………………………………………………………………………………………. 44

Annex 3…………………………………………………………………………………………………………… 45

Annex 4…………………………………………………………………………………………………………… 61

Indonesian SRS 2014 x

LIST OF TABLES

Table No. Table Name Page No.

Table 4.1 Total Population, total number of subdistrict, and average number of population in subdistrict by District and City, Population Census 2010 and Village Potency Survey 2008

7

Table 5.1 Health Outcome Indicators (With Adjustment), Indonesia 2014

10

Table 5.2 Progress of Health Outcome Indicators (MDGs: 1991 & 2015); DHS 2012 & SRS 2014

11

Table 5.3 Distribution of Proportion of Deaths by Sex and Age Group, Indonesian SRS 2014

12

Table 5.4 Twenty Leading Underlying Causes of Death (Males & Females), Indonesian SRS, 2014

14

Table 5.5 Twenty Leading Underlying Causes of Death among Males Indonesian SRS, 2014

15

Table 5.6 Twenty Leading Underlying Causes of Death among Females, Indonesian SRS, 2014

16

Table 5.7 Distribution of Maternal Mortality By Cause, Indonesian SRS, 2014

18

Table 5.8 Leading Underlying Causes of Death among Neonatal, Indonesian SRS, 2014

19

Table 5.9 Leading Underlying Causes of Death among Neonatal, Indonesian SRS, 2014

20

Table 5.10 Leading Underlying Causes of Death among Late Neonatal (8-28 days), Indonesian SRS, 2014

21

Table 5.11 Leading Underlying Causes of Death among Infants, Indonesian SRS, 2014

22

Indonesian SRS 2014 xi

Table 5.12 Leading Underlying Causes of Death among Children Aged 1-4 Years, Indonesian SRS, 2014

23

Table 5.13 Leading Underlying Causes of Death among Children Underfives (aged 0-59 months), Indonesian SRS, 2014

24

Table 5.14 Leading Underlying Causes of Death among Children Aged 5-14 Years, Indonesian SRS, 2014

25

Table 5.15 Leading Underlying Causes of Death among Population Aged 15-44 Years, Indonesian SRS, 2014

26

Table 5.16 Leading underlying causes of death among Population Aged 45-59 years, Indonesian SRS, 2014

27

Table 5.17 Leading underlying causes of death among the elderly aged 60 + years, Indonesian SRS, 2014

28

Table 5.18 Distribution of Injury Mortality by External Causes, Indonesian SRS, 2014

31

Table 5.19 Distribution of Injury Mortality by Type of Transport, Indonesian SRS, 2014

32

Table 5.20 Proportion of Deaths due to HIV/AIDS, Tuberculosis and Malaria from Total Deaths, Indonesian SRS, 2014

33

Indonesian SRS 2014 xii

FIGURES

Figure No. Figure Name Page No.

Figure 1.1 Stages of Vital Registration

3

Figure 4.1 Map of SRS Region, 2014

7

Figure 5.1 Distribution of Proportion of Deaths by Sex and Age Group, Indonesian SRS 2014

13

Figure 5.2 Distribution of Deaths by Place of Event, Indonesian SRS, 2014

13

Figure 5.3 Distribution of Maternal Mortality into proportion (%) of Direct and Indirect Obstetric of Obstetric Deaths, Indonesian SRS, 2014

17

Figure 5.4 Distribution of Maternal Deaths by Place of Death, Indonesian SRS, 2014

18

Figure 5.5 Proportion of Neonatal Deaths by Place of Death, Indonesian SRS 2014

22

Figure 5.6 Distribution of Mortality due to Cerebrovascular Diseases (Stroke) by Age Group, Indonesian SRS, 2014

29

Figure 5.7 Distribution of Mortality due to Ischaemic Heart Disease by Age Group, Indonesian SRS, 2014

30

Figure 5.8 Distribution of Mortality due to Transport Accidents by Age Group, Indonesian SRS, 2014

31

Indonesian SRS 2014 xiii

EXECUTIVE SUMMARY

Accurate basic demographic statistics (births, deaths, marriage, migration) are basis for

formulation of health policies and management of effective government. Mortality statistics,

death certificate as well as medical certificate of multiple causes of death from hospitals are

incomplete, due to the limited utilization of the hospitalization services.The benefits of a well-

developed information system include the ability to monitor impact of health programs, better

quality information, and enable more efficient delivery of health care services.

The Objectives of the SAMPLE REGISTRATION SYSTEM (SRS) were to generate reliable estimates

of national outcome indicators and multiple causes of deaths (in accordance with ICD-10) that

include Cause Specific Mortality Rate of major diseases annually (within the framework of Law

No. 23/2006 and Law No. 24/2013 on Population Administration), as well as to obtain

representative national outcome indicators (Maternal Mortality Ratio/MMR, Neonatal

Mortality Rate/NMR, Infant Mortality Rate/IMR, Under fives mortality rate) and fulfilling the

need to monitor achievements of MDGs 4, 5 and 6.

All data in SRS (including the death events at hospital) were collected by trained paramedical

personnel through household visits, using WHO Standard Verbal Autopsy instruments (paper &

pencil) and the diagnosis verified by trained physicians. The main components of SRS, include

continuous (longitudinal) enumeration of vital events, an independent survey for recording

births and deaths, matching of events recorded during continuous enumeration and those

listed in survey (capture and recapture) and field verification of unmatched and partially

matched events.

Indonesian SRS 2014 xiv

Selection of National Representative of SRS Sites was conducted using Village Potency Survey

(PODES) data; a total of 128 sites in 119 districts or cities in 30 provinces was selected.

Indonesian SRS sites cover 128 subdistricts in 119 Districts and cities, located in 30 provinces

with total population covered about 3.5 % of total Population, that is about 8.8 millions.

Collected live births data in 128 SRS sites, adjusted by projection of 2010 Population Census for

2014 and updated Population Administration data from Ministry of Home Affairs was used as

denominator.

Standard Verbal Autopsy instruments were used for interviews with family members and/or

caregivers. ICD-10 rules and coding system were applied to the results of verbal autopsy

interviews. Respondents were primary care-giver (usually family member) who were with the

deceased prior to death event, Verbal autopsy instruments consist of 3 types, that is Instrument

for neonatal cases (aged less than 4 weeks), Instrument for Infant and child cases (aged 4 weeks

to 14 years) and Instrument for adult cases (aged 15 years and over)

RESULTS. Total population observed was 8.898.429 and total death cases found from

January 1, 2014 to December 31, 2014 were 41,590; that consisted of 927 Neonates ( 0-28

days), 1,065 aged 29 days-14 years and 39,598 aged 15 years and above. The crude coverage

was 73.0 % by applying CDR used to set target (National Projection for 2014) of 6.4 per 1,000

population

POLICY IMPLICATIONS. Indonesia needs to enhance the efforts to improve the population

health status. To accelerate reduction of the Burden of Non Communicable Diseases and

Injuries, special efforts should be prioritized, planned and implemented; such as Control of

major risk factors of Non-Communicable Diseases (unhealthy diet including reduction of salt

consumption and avoiding high total cholesterol food, controlling high blood pressure and

smoking behavior). Special preventive efforts by the health sector and other related sectors

should be carried out to control road traffic injuries and other unnatural deaths.

Indonesian SRS 2014 xv

Despite sustained and rapid reduction in child mortality, a substantial fraction of the burden of

disease was due to premature mortality in children. Neonatal causes, diarrhea and pneumonia

were the major causes. There are need to introduce low cost & simple resuscitation kit for

asphyxiated baby in standard midwifery kit, incorporating PCV-13 and Rotavirus Vaccines in

routine immunization program, revitalization of community knowledge & practices on diarrhea

management and use of ORT.

There are also urgent need to improve the quality and quantity of maternity and neonatal care

through Basic and Comprehensive Emergency Maternal and Neonatal Care (PONED & PONEK)

facilities as well as the referral system; that require improved, integrated and comprehensive

efforts.

Stroke was not only the top leading cause of mortality (21.1 % of total); it is also the disease

with the biggest gap between Indonesia and comparator countries. Key factors include high

level of hypertension, high tobacco consumption, poor diet especially high sodium and glucose

consumption and low fruit consumption, lack of physical activity as well as the inadequate

management of Diabetes Mellitus. Two key strategies to curb high stroke rates include risk

factor reduction through public health campaign, taxation and legislation, and blood pressure

management through effective diagnosis, treatment and follow up in primary care facilities.

Tuberculosis was the fourth leading cause of mortality, with 5.7 % from total cases. Results of

2013-2014 TB Prevalence Survey showed the prevalence of 759 per 100,000 population,

significantly increased (more than doubled) compared with previous findings. Case detection

rates need to be increased through better diagnostic capabilities in the peripheral health

system facilities (chest X-Ray, bacteriological culture, training of personnel).

Road traffic injuries (dominated by motor-cycles) are the main cause of injury burden and

maintained steadily. At present, it causes annual deaths about 26,000 and has the potential for

burden reduction. Successful multi-sector approaches to reduce road traffic injuries are

Indonesian SRS 2014 xvi

needed, including road safety engineering, traffic calming, separation of pedestrians from

traffic, seat-belt & helmet law enforcement, and enforcement of vehicle safety standards.

Incidence of Diabetes Mellitus and Chronic Kidney Diseases have increased by 86% and 90%

respectively in the last 25 years. Indonesia needs to enhance the management of

complications, such as retinopathy, nephropathy, neuropathy and cardiovascular

complications, through improved primary care programs

SRS found that tobacco related diseases were still high in Indonesia. About 36.3 % of population

and 65 % among males alone were active smokers (Riskesdas 2013). Rising burden in men

means that tobacco’s toll in Indonesia is nearly equal to the developed countries situation in

1990. Intensified tobacco control efforts following the MPOWER/ WHO Policy package and

FCTC are urgently needed.

Finally, incorporating all sources of Vital Registry, namely hospital data (multiple causes of

death based on ICD-10), community based mortality data (Verbal Autopsy) and unnatural death

data from Local Police and Forensic Department of Hospitals should be accelerated under the

umbrella of Civil Registration and Vital Statistics (CRVS).

Indonesian SRS 2014 1

1. BACKGROUND

Accurate basic demographic statistics (births, deaths, marriage, migration) are fundamental

evidence fundamental evidence for the formulation of health policies and management of

effective government. In Indonesia at present, mortality statistics, death certificates as well

as medical certificate of cause of death from hospitals are incomplete, due to the limited

utilization of hospital services. Baseline Health Research 2013 found that only 2.3 % of the

Indonesian people use hospital in-patient services and only 10.4 % use out-patient services

in one year.

Sources of Health Information System and basic demographic statistics in Indonesia include:

Population Administration Information System (SIAK), Population Census, National

Socioeconomic Survey, Demographic Health Survey, National Health Survey, Baseline Health

Research (RisKesDas), regular recording-reporting system of Puskesmas (Community Health

Center) and Hospitals, surveillance data (nutrition, Maternal & Child Health including results

of Audit Maternal Perinatal), sentinel data for mortality (IMRSSP), Family Planning reporting

system, and others.

In the past, the mortality registration system in Indonesia has not provided the needed

information on number and causes of death at national and local (provincial, district & city)

levels due to severe under reporting.

For more than two decades, the Ministry of Health has used results of community based

mortality surveys using verbal autopsy instruments, to obtain multiple causes of death

(underlying, antecedent and direct cause) and to determine mortality levels that were

severely under reported (about thirty five percent).

Calculating outcome indicators (Infant Mortality Rate, Under Five Mortality Rate, Maternal

Mortality Rate, etc.) using indirect methods or survey data will only describe the situation

about four to five years before the survey was conducted. This makes it difficult to monitor

achievements of MDGs 4,5,6; construct life tables or calculate various outcome indicators in

real-time (current).


The benefits of a well-developed vital registration system include the ability to monitor the

impact of health programs, better quality information, and more efficient delivery of health

care services. With sound data sources and proper data collection, data and evidence can

be transformed into policy using best practices.

With the need to monitor and evaluate Millennium Development Goals especially MDGs 4

(infant & child mortality), 5 (maternal mortality) and 6 (deaths due to HIV/AIDS, Malaria and

Tuberculosis), the Center for Community Empowerment, Health Policy and Humanities -

National Institute of Health Research and Development, Ministry of Health has initiated a

nationally representative Sample Registration System (SRS) that consolidates mechanisms

for collection, analysis and calculation of mortality statistics within the broader process of

civil registration in Indonesia, towards generating reliable estimates of national

representative outcome indicators (Crude Birth Rate, Total Fertility Rate, Crude Death Rate,

Infant Mortality Rate, Maternal Mortality Rate, etc.) and multiple causes of death annually.

The main components of the Indonesian Sample Registration System (SRS) include, among

others:

a. Optimization of the 2010 Population Census and its projection for 2014, as the base-

line population.

b. Continuous (longitudinal) enumeration of vital events based on Population

Administration Law

c. An independent half-yearly survey for recording and verification of births and deaths

d. Matching of events recorded during continuous enumeration and those listed in the

survey;

e. Field verification of unmatched and partially matched events

f. Provision of SRS sites as field laboratories for piloting and evaluation of various public

health interventions

The Indonesian SRS can be considered an intermediate objective, before achieving an

established and complete vital registration system all over the country (Figure 1), as

envisaged in the 2006 and 2013 Population Administration Law.


Figure 1.1. Stages of Vital Registration


2. OBJECTIVES

The General Objective in developing the Indonesian SRS is to generate reliable

representative estimates of national outcome indicators (Crude Birth Rate, Crude Death

Rate, Neonatal Mortality Rate, Infant Mortality Rate, Under five Mortality Rate, Maternal

Mortality Rate, etc.) and multiple causes of deaths based on WHO ICD – 10 (International

Statistical Classification of Diseases and Related Health Problems, Tenth Revision, 1992) for

2014.

2.1. Specific Objectives

a. Specific objectives of the SRS are as follows:To obtain representative national

outcome indicators (also fulfiling the need for monitoring MDGs 4, 5): Crude

Death Rate, Crude Birth Rate, Total Fertility Rate, Infant Mortality Rate,

Neonatal Mortality Rate, Under Five Mortality Rate, Maternal Mortality Ratio;

for 2014

b. To obtain multiple causes of death based on ICD – 10 (MDG 6)

c. To use SRS findings for policy formulation


3. STRATEGIES

3.1. Strategies applied Strategies applied in developing the SRS include:

a. Close collaboration with local government officials at the grass-roots level

(City/District and below) and assignment of the City or District Health Officer

as the responsible officials and Subdistrict Health Center (Puskesmas) as the

responsible health institutions

b. Applying the IMRSSP (Indonesia Mortality Registration System Strengthening

Project) methods and procedures as well as training modules and data

collection framework in SRS areas.

c. Collection of all mortality cases in SRS areas and using Verbal Autopsy

instruments, based on “Verbal Autopsy Standards: ascertaining and

attributing cause of death”, WHO 2007.

d. Applying ICD-10 multiple causes of death and its coding system

e. Establish networking with local subdistrict and village public officials

f. Capacity development of local Puskesmas personnel, to assure completeness

and high quality of data

g. Enforcement of existing Population Administration Laws (Law No. 23/2006 and

Law No. 24/2013) that cover registration of vital events

3.2. Verification of completeness methods:

1. Capture-Recapture Method to assess completeness of registration

2. Validity assessment of reported multiple causes of death data

3. Continuous local data collection over time

4. Uses of cohort data of pregnant mothers and neonates (MCH Handbook/Buku KIA)

5. Regular coordination between population administration officials and health

personnel at village and sub district level


4. METHODS

4.1. Selection of Nationally Representative SRS Sites Indonesia is divided into Cities (representing urban areas) and Districts (representing rural

areas). Using Village Potency Survey (PODES) 2008 data, a total number of subdistricts in

Cities and Districts were identified. Indonesia is stratified into Cities (represent urban) and

Districts (represent rural) using Village Potency Survey 2008 data.

The estimated total population sample needed for SRS was a minimum of 2 % of the total

population (Projected from Population Census 2000: 231,114,483), that is 4,622,290. To

achieve this sample size a total of 25 subdistricts in cities and 103 subdistricts in Districts in

Indonesia were systematically selected as SRS Areas. The average total sub-district

population is 36,033 and the total selected SRS Sites are at least 128 (ANNEX 1)

Subdistricts were selected as the administrative level for SRS Sites, as they are the lowest

administrative Unit with a defined border in a city or district that includes one or more

Community Health Centers (Puskesmas).


Figure 4.1 : Map of SRS Region, 2014 Table 4.1: Total Population, total number of subdistrict, and average number of population in subdistrict by District and City, Population Census 2010 and Village Potency Survey 2008

Area Total no. of populationa

Estimated total no. of population that should be covereda

Total No. of Subdistrictb

Total No. of SRS sites

District 185,983,496 3,830,488 5,767 103

City 46,475,560 929,512 647 25

Total 231,114,483 4,622,290 6,414 128

a Projected Population in 2010 (based on Population Census 2000)

b Village Potency Survey 2008

All data in SRS (including the death events at hospital) were collected by trained paramedical personnel through household visits, using Verbal Autopsy instruments (paper & pencil) and the diagnosis verified by trained physicians

The Joint Decree of the Minister of Home Affairs and the Minister of Health (January 2010)

on Reporting of Death and Cause of Death facilitated the recording of events and

cooperation between the two sectors at the grass-roots level


4.2. Report Mechanism of Death Event

Information on any deaths taking place at home are obtained by the subdistrict health

center through village administrators and health cadres. The trained health center personnel

then visit the house of the deceased and ascertain the history of illness and treatment from

the family using a semi-structured verbal autopsy instrument. Then, the health center

physician will assign the cause of death and the trained coders will provide ICD-10 codes.

For deaths occurring in health facilities (especially hospital), a medical certificate with

multiple causes of death is completed by the attending physician. Completeness of death

registration is asessed by triangulating data from different sources.

Standard instruments are used for interviews with family members and/or caregivers with

the following characteristics:

Respondent should be a primary caregiver (usually family member) who was with the

deceased prior to the death event

Preferably short recall periods are attained (< 3 months)

Adaptation of instruments to the local situation

Verbal autopsy instruments consist of 3 types:

Instrument for neonatal cases (aged <4 weeks)

Instrument for Infant and child cases (aged 4 weeks to 14 years)

Instrument for Adult cases (aged 15 years and over)

4.3. Organization of SRS

Implementation of the Indonesian SRS is coordinated by the Center for Health Systems and

Policy Research & Development – National Institute of Health Research & Development,

Ministry of Health in collaboration with the Directorate General of Population and Civil

Registry - Ministry of Home Affairs.


5. RESULTS

The Indonesian SAMPLE REGISTRATION SYSTEM (SRS) 2014, covers 128 subdistricts in 119

Districts or cities (30 provinces). Total population covered is about 3.5 % of the Total

National Population (240 million), that is 8,898,429, based on 2014 Social Security Data with

unique population ID Number (NIK).

Issuance of the Joint Decree of the Minister of Home Affairs and the Minister of Health

(2010) on Reporting of Death and Cause of Death and sharing of mortality data at the

grassroot level, facilitates the recording and reporting of birth and death events and

cooperation between the two sectors (Home Affairs and Health) at all levels.

Summary of Findings:

1. Total death cases found from January 1, 2014 to December 30, 2014: 41,590

2. Total population observed: 8,898,429

3. Total death cases (Data Analysis), consist of:

a. Aged 0-28 days : 927 cases

b. Aged 29 days-14 years : 1,065 cases

c. Aged 15 years and above : 39,598 cases

4. CDR of 6.4 per 1,000 population (projected from 2010 Population Census) used to set

national target of SRS (National Projection for 2014)

Crude coverage of SRS: 70 %

5. Number of Early Neonatal Death: 768 cases

Number of Intra Uterine Foetal Death (IUFD) : 490 (excluded in analysis)

Total Number of Perinatal Death: 1,258 cases

Denominators are based on:

Collected population data and live birth data in 128 SRS sites, adjusted by projection from

the 2010 Population Census for 2014 & updated Population Administration data from the

Ministry of Home Affairs.


5.1. Health Outcome Indicators

Health outcome indicators in 2014 are calculated, using the results of the Sample

Registration System 2014 with denominators being the population and live births of the

sample area in the same year.

These include: Crude Death Rate (CDR), Maternal Mortality Ratio (MMR), Neonatal Mortality

Rate (NMR), Early Neonatal Mortality Rate (ENMR), Infant Mortality Rate (IMR), Under Five

Mortality Rate (U5MR) and Child Mortality Rate (CMR).

Table 5.1 : Health Outcome Indicators (With Adjustment), Indonesia 2014

Indicators Est SE 95% CI RSE (%) LB UB

CDR Adjusted 7.48 0.31 6.87 8.09 4.1

MMR Adjusted 244.64 26.20 192.79 296.49 10.7

NMR Adjusted 12.88 1.10 10.70 15.07 8.5

ENMR Adjusted 10.59 0.98 8.65 12.53 9.3

IMR Adjusted 18.64 1.50 15.68 21.60 8.0

U5MR Adjusted 22.93 1.85 19.26 26.60 8.1

CMR Adjusted 4.30 0.55 3.20 5.39 12.8

The results show that after adjustment for under-reporting, the outcome indicators for 2014

are as follow:

Crude Death Rate (CDR): 7.48 per 1,000 population (95% CI: 6.87-8.09)

Maternal Mortality Ratio (MMR): 244.64 per 1,000 live births (95% CI: 192.79-296.49)

Neonatal Mortality Rate (NMR): 12.88 per 1,000 live births (95% CI: 10.70-15.07)

Early Neonatal Mortality Rate (ENMR): 10.59 per 1,000 live births (95% CI: 8.65-12.53)

Infant Mortality Rate (IMR): 18.64 per 1,000 live births (95% CI: 15.68-21.60)

Under Fives Mortality Rate (U5MR): 22.93 per 1,000 live births (95% CI: 19.26-26.60)

Child Mortality Rate (CMR): 4.30 per 1,000 live births (95% CI: 3.20-5.39)


Tabel 5.2 : Progress of Health Outcome Indicators (MDGs: 1991 & 2015); DHS 2012 & SRS 2014

No Outcome Indicators Baseline 1991

DHS 2012

SRS 2014

Target 2015

1 Neonatal Mortality Rate 32 19 12.88

2 Early Neonatal Mortality Rate 10.59

3 Infant Mortality Rate (1q0) 68 32 18.64 23

4 Child Mortality Rate (4q1) 34 9 4.30

5 Under-5 Mortality Rate (5q0) 97 40 22.93 32

6 Maternal Mortality Ratio (MMR) 390 359 244.64 102

This Table shows the progress of selected health outcome indicators from 1991 to 2014; and

the Millennium Development Goals 4 and 5 in 2015. All targets show improvement over the

time period covered and all have been reduced to below 2015 targets except the Maternal

Mortality Ratio.


Tabel 5.3 : Distribution of Proportion of Deaths by Sex and Age Group, Indonesian SRS 2014

Age Groups Sex

Total

Male Female

< 1 days 1.0 0.7 0.9

1 - 7 days 1.1 0.8 1.0

8 – 28 days 0.4 0.4 0.4

1 – 11 months 1.1 0.8 1.0

12 – 59 months 0.7 0.7 0.7

5 – 9 years 0.4 0.3 0.3

10 – 14 years 0.5 0.6 0.5

15 – 19 years 1.5 1.1 1.3

20 – 24 years 1.7 1.2 1.5

25 – 29 years 1.8 1.6 1.7

30 – 34 years 2.4 2.1 2.3

35 – 39 years 2.8 2.5 2.6

40 – 44 years 4.2 3.8 4.0

45 – 49 years 5.9 5.3 5.6

50 -54 years 8.3 7.3 7.9

55 – 59 years 9.6 8.2 9.0

60 – 64 years 10.9 9.0 10.0

65 – 69 years 9.6 9.3 9.5

70 – 74 years 12.0 12.1 12.0

75 – 79 years 9.0 9.5 9.2

80 – 84 years 7.5 10.5 8.9

≥ 85 years 7.4 12.1 9.6

The table show the distribution of proportion of deaths by sex and age group in the SRS Area

in 2014.


Figure 5.1 : Distribution of Proportion of Deaths by Sex and Age Group, Indonesian SRS 2014

Figure 5.2 : Distribution of Deaths by Place of Event, Indonesian SRS, 2014


The highest proportion of deaths occurred at homes (64.5 %), followed by at hospitals (30.1

%), other places (3.4 %) and at other health facilities (1.5 %).

Table 5.4 : Twenty Leading Underlying Causes of Death (Males & Females),

Indonesian SRS, 2014

No Cause of Death (ICD 10) %

1 Cerebrovascular diseases (I60 - I69) 21.1

2 Ischaemic heart diseases (I20 – I25) 12.9

3 Diabetes mellitus with complication (E10 – E14) 6.7

4 Respiratory tuberculosis (A15 – A16) 5.7

5 Hypertensive diseases with complication (I11 – I13) 5.3

6 Chronic lower respiratory diseases (J40-J47) 4.9

7 Diseases of the liver (K70 – K76) 2.7

8 Transport accidents (V01– V99) 2.6

9 Pneumonia (J12 – J18) 2.1

10 Diarrhoea and gastroenteritis of presumed infectious origin (A09) 1.9

11 Malnutrition (E40 – E46) 1.2

12 Falls (W00 – W19) 1.2

13 Malignant neoplasm of breast (C50) 1.0

14 Disorders relating to length of gestation and fetal growth (P05– P07) 0.9

15 Malignant neoplasm of liver and intrahepatic bile ducts (C22) 0.7

16 Viral hepatitis (B15 – B19) 0.6

17 Intrauterine hypoxia and birth asphyxia (P20 - P21) 0.6

18 Gastric and duodenal ulcer (K25-K27) 0.6

19 Malignant neoplasm of trachea, bronchus and lung (C33 - C34) 0.6

20 Malignant neoplasm of cervix uteri (C53) 0.5

This Table shows that cerebrovascular diseases, Ischaemic Heart Diseases, Diabetes Mellitus

with complications and Respiratory Tuberculosis were the leading underlying causes of death

for both sexes in 2014.


Table 5.5 : Twenty Leading Underlying Causes of Death among Males Indonesian SRS, 2014


1 Cerebrovascular diseases (I60 – I69) 19.0


3 Respiratory tuberculosis (A15 – A16) 7

4 Chronic lower respiratory diseases (J40 – J47) 6.1

5 Diabetes mellitus with complications (E10 – E14) 5.5

6 Hypertensive diseases with complications (I11 – I13) 4.9

7 Transport accidents (V01 – V99) 3.7




11 Falls (W00 – W19) 1.2


13 Disorders relating to length of gestation and fetal growth (P20 – P21) 0.9


15 Viral hepatitis (B15 – B19) 0.8

16 Malignant neoplasm of trachea and lung (C33 – C34) 0.8

17 Intrauterine hypoxia and birth asphyxia (P20 – P21) 0.7

18 Gastric and duodenal ulcer (K25 – K27) 0.5

19 Malignant neoplasm of lip, oral cavity and pharynx (C00 – C14) 0.5

20 Malignant neoplasm of colon, rectum and anus (C18 – C21) 0.4

This Table shows that cerebrovascular diseases, Ischaemic Heart Diseases, Respiratory

Tuberculosis, Chronic lower respiratory diseases and Diabetes Mellitus with complications

were the leading underlying causes of death among males in 2014.


Table 5.6 : Twenty Leading Underlying Causes of Death among Females, Indonesian SRS, 2014




3 Diabetes mellitus with complications (E10 – E14) 8.1

4 Hypertensive diseases with complications (I11 – I13) 5.8








12 Malignant neoplasm of cervix uteri (C53) 1.1

13 Falls (W00 – W19) 1.1

14 Anaemias (D50 – D64) 1.0


16 Disorder relating to length of gestation and fetal growth (P05 – P08) 0.8

17 Direct obstetric deaths (O10 – O92) 0.7

18 Gastric and duodenal ulcer (K25 – K27) 0.6

19 Intrauterine hypoxia and birth asphyxia (P20 – P21) 0.5


This Table shows that cerebrovascular diseases, Ischaemic Heart Diseases, Diabetes Mellitus

with complications, Hypertensive diseases with complications and Respiratory Tuberculosis

were the leading underlying causes of death among females in 2014.


Maternal Mortality

76.9

23.1

Direct Obstetric DeathsIndirect Obstetric Deaths

Figure 5.3 : Distribution of Maternal Mortality (%) by Direct and Indirect Obstetric Deaths, Indonesian SRS, 2014

There were 182 cases of maternal deaths and 4 cases of late maternal deaths (O96).

The Table below shows the distribution of maternal mortality by cause. Edema, proteinuria

and hypertensive disorders in pregnancy, childbirth and the puerperium; Maternal

haemorrhage and Maternal sepsis and infections were the most common causes of maternal

deaths


Table 5.7 : Distribution of Maternal Mortality By Cause, Indonesian SRS, 2014

No Causes of Maternal Death ICD 10 %

1 Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium

O10 – O16 37.4

2 Maternal haemorrhage O46, O67, O72 16.9 3 Maternal sepsis and maternal infections O85, O98 11.5 4 Complications of the pregnancy, labour,

delivery and puerperium O21, O44, O45, O48, O61, O62, O71, O75, O87, O88, O90

12.9 5 Maternal abortive outcome O01, O03, O06 3.8 6 Other maternal diseases classifiable elsewhere

but complicating pregnancy, childbirth and the puerperium

O99

17.5

74.7

19.2

3.8 2.2

Hospitals Homes Others Other Health Facilities

Figure 5.4: Distribution of Maternal Deaths by Place of Death, Indonesian SRS, 2014


Figure 5.4 shows the Distribution of Maternal Deaths By Place of Death. Most maternal

deaths occurred at the hospital (74.7 %), followed by at home (19.2 %).

Neonatal Mortality Table 5.8 : Leading Underlying Causes of Neonatal deaths, Indonesian SRS, 2014

No Causes of Death (ICD 10) %

1 Disorders relating to length of gestation and fetal growth (P05, P07, P08)

38.8

2 Intrauterine hypoxia and birth asphyxia (P20, P21) 26.5

3 Congenital malformations (Q00 – q99) 12.7

4 Other respiratory conditions of newborn (P24, P25, P28) 4.0 5 Heorrhagic, hematological disorders, kern ikhterus,

neonatal jaundice (P51, P52, P55, P57, P59) 2.2

6 Pneumonia (J18) 2.0 7 Fetus and newborn affected by maternal factors and by

complications of pregnancy labour and delivery (P01, P02, P03)

1.6

8 Respiratory distress of newborn (P22) 1.1

9 Congenital pneumonia (P23) 1.0 10 Diarrhoea and gastroenteritis of presumed infectious

origin (A09) 0.8

Table 5.8, shows the leading underlying causes of death among neonates. The most common

causes are Disorders relating to length of gestation and fetal growth, Intrauterine hypoxia

and birth asphyxia, and Congenital malformations.


Table 5.9: Leading Underlying Causes of Death among Early Neonates (0-7 days), Indonesian SRS, 2014


1 Disorders relating to length of gestation and fetal growth (P05, P07, P08) 40.8

2 Intrauterine hypoxia and birth asphyxia (P20, P21) 30.9

3 Other respiratory conditions of newborn (P24, P25, P28) 4.2

4 Congenital malformations (Q00 – Q99) 1.8 5 Fetus and newborn affected by maternal factors and by complications of

pregnancy labour and delivery (P01, P02, P03)

1.4

6 Heorrhagic, hematological disorders, kern ikhterus, neonatal jaundice (P51, P52, P55, P57, P59)

1.4

7 Congenital pneumonia (P23) 1.0

8 Respiratory distress of newborn (P22) 0.9

9 Tetanus neonatorum (A33) 0.5

10 Sudden infant death syndrome (R95) 0.5

Table 5.9, shows the leading underlying causes of death among early neonates (0-7 days) in

2014. `Disorders relating to length of gestation and fetal growth, Intrauterine hypoxia and

birth asphyxia and Other respiratory conditions of newborn are the most common causes.


Table 5.10 : Leading Underlying Causes of Death among Late Neonates (8-28 days), Indonesian SRS, 2014


1 Disorders relating to length of gestation and fetal growth (P05, P07, P08)

29.6

2 Congenital malformations (Q00 – q99) 17.0

3 Pneumonia (J18) 11.3 4 Intrauterine hypoxia and birth asphyxia (P20, P21) 5.7

5 Haemorrhagic, hematological disorders, kern ikhterus, neonatal jaundice (P51, P52, P55, P57, P59)

5.7

6 Diseases of the digestive system (K56, K57, K92)

3.1

7 Other respiratory conditions of newborn (P24, P25, P28) 3.1

8 Diarrhoea and gastroenteritis of presumed infectious origin (A09)

2.5

9 Fetus and newborn affected by maternal factors and by complications of pregnancy, labour and delivery (P01, P02, P03)

2.5

10 Bacterial sepsis of newborn (P36) 2.5

Table 5.10, shows the leading underlying causes of death among late neonates (8-28 days) in

2014. `Disorders relating to length of gestation and fetal growth, congenital malformation

and Pneumonia are the most prevalent causes.


Figure 5.5: Proportion of Neonatal Deaths by Place of Death, Indonesian SRS 2014

Figure 5.5, shows the Proportion of neonatal deaths by place of death. The majority

occurred at hospitals, followed by homes and other heath facilities.

Infant Mortality

Table 5.11 : Leading Underlying Causes of Death among Infants, Indonesian SRS, 2014


1 Intrauterine hypoxia and birth asphyxia (P20, P21)

18.3

2 Pneumonia (J18)

8.7

3 Diarrhoea and gastroenteritis of presumed infectious origin (A09) 6.5 4

Congenital malformations of the heart (Q21, Q23, Q24) 4.1

5 Meningitis (G03) 2.0 6 Diseases of the digestive system (K46, K56, K57, K63, K74, K75, K83,

K92) 1.9

7 Fetus and newborn affected by maternal factors and by complications of pregnancy labour and delivery (P01, P02, P03)

1.7

8 Haemorrhagic and haematological disorders of fetus and newborn/Haemorrhagic disorder, kern ichterus, jaundice (P51, P52, P55, P57, P59)

1.6 9

Respiratory distress of newborn (P22) 0.8

10 Congenital hydrocephalus and spina bifida (Q03, Q05)

0.8


Table 5.11, shows the leading underlying causes of death among infants. Intrauterine

hypoxia and birth asphyxia; Pneumonia and Diarrhoea and gastroenteritis of presumed

infectious origin were the most common causes.

Child (Under five) Mortality Table 5.12 : Leading Underlying Causes of Death among Children Aged 1-4 Years,

Indonesian SRS, 2014



2 Pneumonia (J12 - J18) 12.9

3 Meningitis (G03) 6.3

4 Diseases of the digestive system (K46, K56, K57, K63, K74, K75, K83, K92) 4.3

5 Accidental drowning and submersion (W65–W74) 4.3

6 Transport accidents (V02, V03, V22, V23, V27-V29, V33, V99) 3.0

7 Malnutrition and other nutritional deficiencies (E40, E41, E44, E46) 2.6

8 Congenital malformations of the heart (Q21, Q23, Q24) 2.6

9 Leukaemia (C91 – C95) 2.0

10 Tuberculosis (A16) 1.3

Table 5.12 , shows the leading underlying causes of death among children aged 1-4 years.

Diarrhoea and gastroenteritis of presumed infectious origin, Pneumonia and Meningitis

were the most common causes.


Table 5.13 : Leading Underlying Causes of Death among Children under five (aged 0-59 months), Indonesian SRS, 2014


1 Disorders relating to length of gestation and fetal growth/premature post-term (P05, P07, P08)

22.6

2 Intrauterine hypoxia and birth asphyxia (P20, P21)

14.9

3 Pneumonia (J12 - J18) 9.4 4 Diarrhoea and gastroenteritis of presumed

infectious origin (A09)

8.5 5 Congenital malformations of the heart (Q21,

Q23, Q24) 3.9

6 Meningitis (G03) 2.8 7 Diseases of the digestive system (K46, K56, K57, K63, K74,

K75, K83, K92)

2.3 8 Fetus and newborn affected by maternal factors and by

complications of pregnancy, labour and delivery (P01 – P03)

1.4

9 Haemorrhagic and haematological disorders of fetus and newborn/Haemorrhagic disorder, kern ichterus, Jaudice (P51, P52, P55, P57, P59)

1.3

10 Accidental drowning and submersion (W65 – W74) 0.9

Table 5.13, shows leading underlying causes of death among children under five (aged 0-59

months) in 2014. Disorders relating to length of gestation and fetal growth/premature post-

term is the highest, followed by Intrauterine hypoxia and birth asphyxia, Pneumonia and

Diarrhoea and gastroenteritis of presumed infectious origin


Children Aged 5 – 14 Years Table 5.14: Leading Underlying Causes of Death among Children Aged 5-14 Years, Indonesian SRS, 2014


1 Transport accidents (V02, V03, V22, V23, V27-V29, V33, V99)

10.7

2 Pneumonia (J12 - J18) 7.4


4 Diseases of the digestive system (K46, K56, K57, K63, K74, K75, K83, K92)

6.3

5 Leukaemia (C91 – C95) 5.2

6 Diarrhoea and gastroenteritis of presumed infectious origin (A09)

3.8

7 Meningitis (G03) 3.6

8 Congenital malformations of the heart (Q21, Q23, Q24) 3.0

9 Tuberculosis (A16) 1.9

10 Malnutrition and other nutritional deficiencies (E40, E41, E44, E46)

1.4

11 Congenital hydrocephalus (Q03) 0.8

12 Human immunodeficiency virus (HIV) disease (B20, B24) 0.5

13 Malaria (B50, B54) 0.5

14 Tetanus (A35) 0.3

15 Accidental poisoning by and exposure to noxious substances (X45)

0.3

Table 5.14 , shows the leading underlying causes of death among children aged 5-14 years in

2014.

The most prevalent cause was Transport accidents, followed by Pneumonia, Accidental

drowning and submersion, Diseases of the digestive system, Leukaemia and Diarrhoea &

gastroenteritis of presumed infectious origin.


Table 5.15: Leading Underlying Causes of Death among Population Aged 15-44 Years, Indonesian SRS, 2014









8 Human immunodeficiency virus/HIV disease (B20 – B24) 2.3



11 Falls (W00 – W19) 1.5

12 Malignant neoplasm of meninges, brain and other parts of central nervous system (C70 – C72)

1.4

13 Viras hepatitis (B15 – B19) 1.4


15 Diarrhea and gastroenteritis of presumed infectious origin (A09) 1.1

16 Malignant neoplasm of servix uteri (C53) 1.1

17 Leukaemia (C91 – C95) 0.9

18 Non Hodgkin’s lymphoma (C82 – C85) 0.9

19 Remainder of certain infectious and parasitic diseases (A21 – A32) 0.9


Table 5.15 , shows the leading underlying causes of death among the population aged 15-44

years in 2014. Transport accidents (V01 – V99) is the highest, followed by Ischaemic heart

diseases (I20 – I25), Respiratory tuberculosis (A15 – A16), Cerebrovascular diseases

(I60 – I69), Diseases of the liver (K70 – K76) and Diabetes mellitus with complication

(E10 – E14).


Table 5.16: Leading Underlying Causes of Death among Population Aged 45 - 59 Years, Indonesian SRS, 2014











10 Falls (W00 – W19) 1.1

11 Malignant neoplasm of servix uteri (C53) 1.0



14 Malignant neoplasm of trachea and lung (C33, C34) 0.9

15 Pneumonia (J12 – J18) 0.8

. Table 5.16 , shows the leading underlying causes of death among the population aged

45 - 59 years in 2014. Cerebrovascular diseases is ranked the first, followed by Ischaemic

heart diseases (I20 – I25), Diabetes mellitus with complication (E10 – E14), Respiratory

tuberculosis (A15 – A16), Hypertensive diseases with complication (I11 – I13), and Diseases

of the liver (K70 – K76).


Table 5.17: Leading underlying causes of death among the elderly aged 60 + years, Indonesian SRS, 2014












11 Falls (W00 – W19) 1.2


13 Gastric and duodenal ulcer (K25, K27) 0.6

14 Malignant neoplasm of liver (C22) 0.5

15 Malignant neoplasm of trachea and lung (C33, C34) 0.5

Table 5.17, shows leading underlying causes of death among the elderly aged 60 years and

above in 2014.

Cerebrovascular diseases is ranked the first, followed by Ischaemic heart diseases (I20 – I25),

Chronic lower respiratory diseases (J40-J47), Diabetes mellitus with complication

(E10 – E14), Hypertensive diseases with complication (I11 – I13) and Respiratory tuberculosis

(A15 – A16).


Figure 5.6 : Distribution of Mortality due to Cerebrovascular Diseases (Stroke) by Age Group, Indonesian SRS, 2014

Figure 5.6, shows that in 2014 Cerebrovascular dIseases (Stroke - one of the main causes of

mortality) started at the age group of 30 – 34 years and kept increasing with the peak at age

group of 70 – 74 years.


Figure 5.7 : Distribution of Mortality due to Ischaemic Heart Disease by Age Group, Indonesian SRS, 2014

Figure 5.7 , shows that in 2014 Ischaemic Heart Diseases as one of the the main cause of

mortality; started at the age group 25 - 29 years and keep increasing with the first peak at

60 – 64 years, and the second peak at 70 – 74 years age group.


Table 5.18 : Distribution of Injury Mortality by External Causes, Indonesian SRS, 2014

No Cause of Death %

1 Transport accidents 51.5

2 Falls 23.0

3 Intentional self-harm 4.7

4 Accidental drowning and submersion 4.3

5 Assault 2.8

6 Accidental poisoning by and exposure to noxious substances 2.2

7 Exposure to smoke, fire and flames 1.0

8 All other external causes 10.6

Total 100.0

Table 5.18, shows the distribution of injury mortality by external causes in 2014.

Transport accidents ranked first, followed by Falls, Intentional self-harm and accidental

drowning and submersion.

Figure 5.8: Distribution of Mortality due to Transport Accidents by Age Group, Indonesian SRS, 2014


Figure 5.8, shows the distribution of mortality due to transport accidents by age

group in 2014. The highest mortality found at 15 – 19 years age group, followed by

25 – 29 years age group and 50 – 54 years age group.

Table 5.19 : Distribution of Injury Mortality by Type of Transport, Indonesian SRS, 2014

No Cause of Death %

1 Motorcycle rider 52.6

2 Pedestrian 14.2

3 Car 3.1

4 Pedal cyclist 1.7

5 Occupant of three-wheeled motor vehicle 1.6

6 Other land transport accidents (train, ect) 1.0

7 Water transport accidents 0.8

8 Occupant of pick-up truck or van 0.7

9 Occupant of heavy transport vehicle 0.2

10 Bus occupant 0.2

11 Unspecified transport accidents 0.2

Total 100.0

Table 5.19, shows the distribution of injury mortality by type of transport in 2014.

The most prevalent mortality cases were motorcycle riders, followed by pedestrians, cars,

pedal cyclists and occupants of three-wheeled motor vehicle.


Table 5.20: Proportion of Deaths due to HIV/AIDS, Tuberculosis and Malaria from Total Deaths, Indonesian SRS, 2014

No Cause of Death %

1 HIV/AIDS 0.4

2 Tuberculosis 5.7

3 Malaria 0.1

Table 5.20, shows the proportion of deaths due to HIV/AIDS, Tuberculosis and Malaria from

total deaths in 2014.

Tuberculosis ranked first, followed by HIV/AIDS and Malaria.


6. CONCLUSIONS

POLICY IMPLICATIONS OF THE FINDINGS

Indonesia needs to accelerate efforts to improve population health status. To accelerate

reduction of the Burden of Non Communicable Disease and Injuries, special efforts should

be prioritized, planned and implemented; among others:

Control of major risk factors of Non-Communicable Diseases: unhealthy diet including

reduction of salt consumption and avoiding high total cholesterol food, controlling high

blood pressure and smoking behavior

Special preventive efforts by the health sector and other related sectors should be carried

out to control road traffic injuries and other unnatural deaths

Unfinished Agenda for Neonatal, Infant, Child and Maternal Mortality

Despite sustained and rapid reduction in child mortality, a substantial fraction of the burden

of disease is due to premature mortality in children. Neonatal causes, diarrhea and

pneumonia are the major causes. There is a need to introduce low cost & simple

Resuscitation Kits for asphyxiated babies in standard midwifery kits, to incorporate PCV-13

and Rotavirus Vaccines in routine immunization program, revitalization of community

knowledge & practices on diarrhea management and use of ORT

Improvement in the quality and quantity of maternity and neonatal care through Basic and

Comprehensive Emergency Maternal and Neonatal Care (PONED & PONEK facilities) is

urgently needed as well as the referral system; these require improved, integrated and

comprehensive efforts. Promotion of Ultrasound use by trained midwives in Puskesmas and

Polindes, is also needed to assist early identification of selected obstetric complications.

CONTROL OF STROKE Stroke is not only the top leading cause of mortality (21.1 % of total); it is also the disease

with the biggest gap between Indonesia and comparator countries.


Key factors include high level of hypertension, high tobacco consumption, poor diet

especially high sodium and glucose consumption and low fruit consumption, lack of physical

activity as well as the inadequate management of Diabetes Mellitus

Two key strategies to curb high stroke rates are:

1. Risk factor reduction through public health campaign, taxation and legislation.

2. Blood pressure management through effective diagnosis, treatment and follow up in

primary care facilities

ACCELERATING PROGRESS ON TUBERCULOSIS CONTROL Despite a 37% reduction in age-standardized tuberculosis death rates between 1990 and

2010, TB is the fourth leading cause of mortality, with 5.7 % of total cases. Results of 2013-

2014 TB Prevalence Survey showed a prevalence of 759 per 100,000 population, significantly

higher (more than doubled) when compared with previous findings

Case detection rates need to be increased through better diagnostic capabilities in the

peripheral health system facilities (chest X-Ray, bacteriological culture, training of personnel)

Given the unusually high burden of tuberculosis in Indonesia over decades, other strategies

including management of Multi Drug Resistant Cases (MDR) and Co-infection with HIV

should be considered.

ROAD TRAFFIC INJURIES Road traffic injuries (dominated by motor-cycles) are the main cause of injury burden and

rates have been consistently high. At present, road traffic injury causes about 30,000 annual

deaths nationally and has the potential for burden reduction.

Indonesia has the highest rates of road traffic injuries among comparator nations.

Successful multi-sector approaches to reduce road traffic injuries are needed, including road

safety engineering, traffic calming, separation of pedestrians from traffic, seat-belt & helmet

law enforcement, and enforcement of vehicle safety standards.


MASSIVE RISE OF DIABETES AND CHRONIC KIDNEY DISEASES Incidence of Diabetes Mellitus and Chronic Kidney Diseases have increased by 86% and 90%

respectively in the last 25 years. Disease burden and health care expenditures on these

conditions will steadily grow and the cost per case is very high. Prevention strategies such as

encouraging routine physical activity and weight reduction need to be accelerated.

Indonesia needs to enhance the management of complications, such as retinopathy,

nephropathy, neuropathy and cardiovascular complications, through improved primary care

programs.

TOBACCO CONTROL Tobacco consumption is still high in Indonesia, 36.3 % of population and 65 % of males alone

are active smokers (Basic Health Research/Riskesdas 2013). The rising burden in men means

that tobacco’s toll in Indonesia is nearly equal to the developed country situation in 1990.

The tobacco attributable disease burden will continue to rise due to current patterns of

consumption and inadequate tobacco control efforts. Future costs in terms of cardiovascular

and cerebrovascular diseases, cancers and other tobacco related diseases will be very large.

Intensified tobacco control efforts following the MPOWER/ WHO Policy package and FCTC

are urgently needed

IMPLICATIONS FOR NATIONAL HEALTH INSURANCE (JKN) The burden of disease in terms of incidence and prevalence of Non Communicable Diseases

and Injuries, along with information on likely costs per case treated, should be used to

forecast the financial burdens that should be expected due to the demographic and

epidemiological transition.

Instituting disease expenditure tracking and linkage to ongoing updates of the burden of

disease should be used to anticipate high health care costs, including the burden for the

health sector and the National Health Insurance (BPJS - JKN).


EXIT STRATEGY OF SRS: CIVIL REGISTRATION & VITAL STATISTICS (CRVS) The development of Civil Registration and Vital Statistics (CRVS) is being used as an exit

strategy for the SRS in 7 Districts/Cities in 2014-2015; applying “Universal Coverage”

approach of civil registration and using “Paperless Method” (Tablet Computer and PC). IHME

(Institute of Health Metrics and Evaluation, Seattle, USA) - Verbal Autopsy Data Collection &

Diagnosis softwares (PHMRC & SMART VA) are being used and later will be updated with

2014 WHO VA Instruments & softwares. Internet/Flash-Disk/SD Card are used to send

collected data to District/City Health Offices.

Civil Registration Data will be used for producing Vital Statistics at city and district level.

CRVS incorporates all sources of Vital Registry, namely: Hospital data (multiple causes of

death based on ICD-10), Community based mortality data (Verbal Autopsy) for those who

died in the community and unnatural death data from Local Police and Forensic Department

of local Hospitals.


REFERENCES

International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, World Health Organization, Geneva 1992. Verbal autopsy standards : ascertaining and attributing cause of death, WHO 2007 Village Potency Survey 2008, Central Bureau of Statistics - BPS, Jakarta 2008 Indonesia Population Projection, 2010-2035. BPS – Statistics Indonesia, Jakarta 2013 S. Preston KH. Estimating the completeness of death registration. Population Studies: A Journal of Demography. 1980;34(2):18. Christopher JL Murray JKR, Jacob Marcus, Thomas Laakso, Alan D. Lopez. What Can We Conclude from Death Registration? Improved Methods for Evaluating Completeness. PloS Medicine. 2010. Christopher JL Murray, Alan D Lopez, Kenji Shibuya, Rafael Lozano. Verbal autopsy: advancing science, facilitating application (Editorial). Population Health Metrics 2011, 9:18 (27 July 2011) Daniel Chandramohan. Validation and validity of verbal autopsy procedures (Commentary). Population Health Metrics 2011, 9:22 (1 August 2011) Philip W. Setel, Osman Sankoh, Chalapati Rao, Victoria A. Velkoff, Colin Mathers, Yang Gonghuan, et al. Sample registration of vital events with verbal autopsy: a renewed commitment to measuring and monitoring vital statistics. Bulletin of WHO. 2005;83(8):7.

Philip W. Setel. Verbal Autopsy and global mortality statistics: if not now, then when?.

Population Health Metrics 2011, 9:20 (27 July 2011)

Sheila S Mudenda et al. Feasibility of using a World Health Organization-standard

methodology for Sample Vital Registration with Verbal Autopsy (SAVVY) to report

leading causes of death in Zambia: results of a pilot in four provinces, 2010.

Population Health Metrics 2011, 9:40 (5 August 2011)


ANNEX 1

LIST OF DISTRICT & CITY, SUBDISTRICT AND NUMBER OF POPULATION OF SRS SITE, INDONESIA 2014


DISTRICT ID CODE NAME OF DISTRICT NAME OF SUBDISTRICT

1101010 SIMEULUE TEUPAH SELATAN 1109100 PIDIE TANGSE 1115030 NAGAN RAYA BEUTONG 1204080 TAPANULI TENGAH MANDUAMAS 1208070 ASAHAN AIR BATU 1211130 KARO BARUSJAHE 1213030 LANGKAT SEI BINGAI 1218051 SERDANG BEDAGAI TEBING SYAHBANDAR 1303050 SOLOK LEMBAH GUMANTI 1308021 LIMA PULUH KOTA LAREH SAGO HALABAN

1403011 INDRAGIRI HILIR KEMUNING 1406080 KAMPAR SIAK HULU 1501060 KERINCI SUNGAI PENUH 1508010 TEBO TEBO ILIR 1603040 MUARA ENIM LAWANG KIDUL 1606090 MUSI BANYUASIN SUNGAI LILIN

1609090 OGAN KOMERING ULU TIMUR SEMENDAWAI SUKU III

1705041 SELUMA SELUMA SELATAN 1802110 TANGGAMUS CUKUH BALAK 1804100 LAMPUNG TIMUR PEKALONGAN 1806080 LAMPUNG UTARA SUNGKAI UTARA 1901090 BANGKA SUNGAI LIAT

3201030 BOGOR PAMIJAHAN 3201180 BOGOR CILEUNGSI 3201280 BOGOR JASINGA 3202211 SUKABUMI CICANTAYAN 3203150 CIANJUR SUKALUYU 3204090 BANDUNG CIKANCUNG 3204280 BANDUNG BOJONGSOANG 3205200 GARUT KARANGPAWITAN 3206161 TASIKMALAYA GUNUNGTANJUNG 3207221 CIAMIS SINDANGKASIH 3209040 CIREBON BABAKAN 3209230 CIREBON GEGESIK

3211061 SUMEDANG GANEAS 3212170 INDRAMAYU LOHBENER 3213210 SUBANG LEGONKULON 3215090 KARAWANG LEMAHABANG 3216070 BEKASI CIBITUNG 3217070 BANDUNG BARAT BATUJAJAR


ID CODE NAME OF DISTRICT NAME OF SUBDISTRICT

3301120 CILACAP KAWUNGANTEN 3302160 BANYUMAS PEKUNCEN 3304030 BANJARNEGARA MANDIRAJA 3305180 KEBUMEN SEMPOR 3307130 WONOSOBO KEJAJAR 3309120 BOYOLALI NOGOSARI 3311030 SUKOHARJO TAWANGSARI 3312240 WONOGIRI GIRIMARTO 3315010 GROBOGAN KEDUNGJATI 3316090 BLORA JEPON 3318110 PATI GABUS 3320070 JEPARA TAHUNAN 3322031 SEMARANG KALIWUNGU

3324080 KENDAL KALIWUNGU 3326110 PEKALONGAN BOJONG 3327130 PEMALANG ULUJAMI 3329030 BREBES BUMIAYU 3401050 KULON PROGO LENDAH 3403140 GUNUNG KIDUL NGAWEN 3502050 PONOROGO SAWOO 3504080 TULUNGAGUNG REJOTANGAN 3505210 BLITAR WONODADI 3507040 MALANG BANTUR 3507280 MALANG SINGOSARI 3509040 JEMBER WULUHAN

3509730 JEMBER PATRANG 3511040 BONDOWOSO PUJER 3513140 PROBOLINGGO BESUK 3514220 PASURUAN GRATI 3516010 MOJOKERTO JATIREJO 3517130 JOMBANG JOMBANG 3519060 MADIUN KARE 3521130 NGAWI KEDUNGGALAR 3523070 TUBAN SOKO 3524200 LAMONGAN KARANG GENENG 3526070 BANGKALAN GALIS 3528060 PAMEKASAN PROPPO 3601061 PANDEGLANG SOBANG

3602160 LEBAK WARUNGGUNUNG 3603100 TANGERANG CIPUTAT 3603210 TANGERANG KOSAMBI 5102020 TABANAN KERAMBITAN 5107040 KARANG ASEM KARANGASEM 5202020 LOMBOK TENGAH PUJUT


ID CODE NAME OF DISTRICT NAME OF SUBDISTRICT

5203090 LOMBOK TIMUR AIKMEL 5303111 KUPANG NEKAMESE 5309072 FLORES TIMUR WITIHAMA 5319010 MANGGARAI TIMUR BORONG 6105150 SANGGAU TAYAN HILIR 6112050 KUBU RAYA SUNGAI KAKAP 6209090 KATINGAN SANAMAN MANTIKEI 6307060 HULU SUNGAI TENGAH LABUAN AMAS SELATAN 6404010 KUTAI TIMUR MUARA ANCALONG 7105100 MINAHASA SELATAN TENGA 7205130 DONGGALA BALAESANG 7304021 JENEPONTO BONTORAMBA 7309070 PANGKAJENE KEPULAUAN LABAKKANG

7314080 SIDENRENG RAPPANG DUAPITUE 7325031 LUWU TIMUR TOMONI TIMUR 7408061 KOLAKA UTARA POREHU 7604030 MAMUJU KALUKKU 8204022 HALMAHERA SELATAN OBI TIMUR 9403230 JAYAPURA SENTANI

CITY ID CODE

NAME OF CITY NAME OF SUBDISTRICT

1171010 BANDA ACEH MEURAXA 1275050 MEDAN MEDAN AREA

1275200 MEDAN MEDAN MARELAN 1471010 PEKANBARU TAMPAN 1671021 PALEMBANG KERTAPATI 1771031 BENGKULU SUNGAI SERUT 2172010 TANJUNG PINANG BUKIT BESTARI 3171100 JAKARTA SELATAN SETIA BUDI 3172090 JAKARTA TIMUR PULO GADUNG 3174030 JAKARTA BARAT PALMERAH 3175040 JAKARTA UTARA KOJA 3273030 BANDUNG BOJONGLOA KALER 3273260 BANDUNG CIDADAP 3275061 BEKASI MEDAN SATRIA

3277020 KOTA CIMAHI CIMAHI TENGAH 3373040 SALATIGA SIDOREJO 3376010 TEGAL TEGAL SELATAN 3573050 MALANG LOWOKWARU 3578130 SURABAYA WIYUNG 3578281 SURABAYA PAKAL


ID CODE

NAME OF CITY NAME OF SUBDISTRICT

3672022 CILEGON PURWAKARTA 5371030 KUPANG OEBOBO 6471010 BALIKPAPAN BALIKPAPAN SELAT 7172011 BITUNG MATUARI 7371111 MAKASSAR TAMALANREA


ANNEX 2

MONITORING AND EVALUATION FRAMEWORK FOR SAMPLE REGISTRATION SYSTEM (SRS)


Indicator Name Baseline Target Data

Source Achievement

Percentage of Sub-Districts

submitting mortality report

with validated multiple causes

of death (using ICD-10)

1.5 % (2009)

24 % (2012)

63 % (2013)

84 % (2014)

SRS

100 % of

Subdistricts (128)


ANNEX 3

SAMPLE REGISTRATION SYSTEM: WEIGHTING AND ESTIMATION


Weighting

Initial sampling design weight

Based on sampling methods in the SRS, the initial sampling design weight was calculated

using the formula:

: is the total population of Indonesia from Podes 2008

: is the number of population in the subdistrict from Podes 2008

n: is the number of selected subdistricts (n=128)

From the results of the weight calculation above, there is one subdistrict, Obi Timur, District

of Halmahera Selatan, which has a very different weight than the other districts. This can lead

to overestimation of the standard error. For adjustment to the sub-district level it is necessary

to maintain unchanged the estimated total population. This will affect the value of weights for

other districts.

Figure 1 below shows the result of a plot between the initial design weights with adjustment

(trimmed) weight for each district selected. Subdistricts are sorted by weight of the smallest

value.

Figure 1 Plot initial design weight and trimmed weight by subdistricts

Weight results are then used to calculate the estimated number of population by sex and age

group recording the results of the population in each subdistrict selected according to the

administration and population division, the Ministry of Home Affairs.


with:

is the estimated by sex j by age groups k

is trimmed weight of subdistrict i

is number of population 2014 (sources from the Ministry of home affair) at subdistricts

i, sex j, and age groups k

Results obtained from population counts approximate the total population in 2014 to be

246,648,142 with the male population being 126,393,358 and female population being

120,254,784. Estimates of population by age group and sex can be seen in Appendix 1. The

age and sex structure of the population estimates using data from the Ministry of Home

Affairs can be seen in Figure 2.

Figure 2 Distribution of the estimated number of population by age group, using data from

the Ministry of Home Affairs and using the trimmed weight

There was quite a large difference between the estimated population size using Ministry of

Interior data when compared to the estimated number of population according to the

projection in 2014 (BPS and Bappenas). The projection showed a population of 252,164,786

with a total population of 126,715,188 males and a female population of 125,449,598. This

difference is also seen in the age structure (see Figure 3). The results of 2014 population

projections by sex and age groups listed in Appendix 2.


Figure 3 Distribution of population by age group from projected population 2014

The results using SP 2010 data produce a population structure according to sex and age group

which is slightly different again, especially in the age group 15-24 years (see Figure 4).

Figure 4 Distribution of population by age group from SP 2010

From the comparison of the total population and the population structure according to sex and

age group, the team agreed to use the total population by gender based on the results of


projected population in 2014 and population age structure for each sex using SP 2010 results,

in calculating the adjustment weight. Adjustment weight by sex and age groups are needed in

order to ensure the total population according to the survey results are the same as the

population according to 2014 projections.

Sex-age specific cell adjustment weight

The sex-age specific cell adjustment weight ( ) is used as a control in order to ensure the

total population by gender and age group is equal to the total population by sex and age group

in the projected population for 2014.

with:


is the estimated population by sex j age groups k from 2014 projected populations

is the estimated population by sex j age groups k from SP 2010

Results of counting the estimated number of population by sex and age groups using cell

adjustment weight can be found in Appendix 3 and the structure of age groups in Figure 5.

Figure 5 Distribution of survey result population by age group with cell adjustment weight

applied


For maternal mortality indicators, weight adjustment was calculated by the formula:

with:

is trimmed weight os subdistrict i

is the estimated population of women aged 15-49 years from 2014 projected results

is the estimated population of women aged 15-49 years from survey 2010

For infant and child mortality indicators, weight adjustment was calculated by the formula:

with:


is the estimated number of population aged 0-4 year from 2014 projected results

is the estimated number of population aged 0-4 year from survey 2010

Under reporting adjustment weight

To calculate the weight adjustment for under-reporting we need to know the coverage level of

deaths reported in the SRS. However, this coverage number of reported deaths is unknown.

Using the Preston-Coale method the Construction of Life Table Indonesia report based on the

2010 Population Census data (Ezra Suhaimi, UNFPA, 2014, the report is limited) estimates

data coverage for deaths in SP2010 by province ranged from 10-57% (see Appendix 4)

Mortality data collection methods in SRS differ from the SP2010. Methods of data collection

in the SRS are believed to produce better coverage. This is because deaths are reported as

they occur whereas SP 2010 data quality is highly dependent on the memory of members of

the household when interviewed.

Results of a study of death registration completeness in 13 villages in Surakarta and 12

villages in the district of Pekalongan, Central Java showed that the levels of coverage of

reporting the incidence of death were respectively 61% and 81%. Assuming that both of these

areas represent the province of Central Java, the difference in the level of coverage in

reporting the incidence of death among SP2010 (45% for men and 39% for women) and SRS

in Central Java can be calculated as follows:

Assuming that the difference in the level of coverage of reporting the incidence of death in

SP2010 and SRS in Central Java province is the same as the other provinces, the rate of

coverage of SRS mortality incident reporting in other provinces can be estimated with:


Calculation of total deaths is carried out using the formula:

with:

D is the total estimated deaths

d ijk is the number of deaths reported in the SRS in the district i, j sex, and age group k

c_ij is the estimated number of deaths events in the district i (assuming all districts in the

same province have an equal coverage value) and sex j

For the calculation of maternal mortality, we then used a value of coverage for women, and

for the calculation of infant or toddler mortality, the coverage number of deaths of women

was used due to their having lower coverage and the coverage number of deaths of infants

and toddlers are believed to be lower than the coverage number deaths of adults.

Estimation

Indicators of mortality are estimated directly using the survey results and then adjusted for

death coverage. Indicators calculated are the following ratios: CDR, MMR, NMR, ENMR,

IMR, under-five mortality, and the mortality rate of children aged 1-4 years.

Estimates are calculated based on two scenarios, namely (1) without adjustment for death

coverage - unadjusted, and (2) adjusted for death coverage - adjusted.

Crude Death Rate (CDR)

CDR figures calculated by the formula :

Unadjusted

Adjusted

Maternal Mortality Rate (MMR)

MMR is calculated by the formula:


Unadjusted

Adjusted

with:

mi is the number of maternal deaths reported in SRS in the sub district i

c_i is an estimate of the coverage of reported incidence of death among women in the district

i (districts in the same province have an equal coverage value)

q_i is the number of births reported in SRS in the sub district i

Neonatal Mortality Rate (NMR)

NMR figures were calculated using the formula:

Unadjusted

Adjusted

with:

d_ ((0-28 days) i) is the number of infant deaths aged 0-28 days reported in SRS in the sub

district i

Early Neonatal Mortality Rate (ENMR)

ENMR figures calculated by the formula:

Unadjusted


Adjusted

with:

d ((0-7 days) i) is the number of infant deaths reported 0-7 days in the SRS in the sub district

i

Infant Mortality Rate (IMR)

IMR figures were calculated by the formula:

Unadjusted

Adjusted

with:

d _ ((<1 yr) i) is the number of infant deaths aged less than 1 year reported in the SRS in sub

district i

Under 5 Mortality Rate (U5MR)

U5MR figures were calculated using the formula:

Unadjusted

Adjusted


with:

ds ((0-4th) i) is the number of deaths of children aged 0-4 years reported in the SRS in sub

district i.

Child Mortality Rate (CMR)

CMR figures were calculated using the formula:

Unadjusted

Adjusted

with:

ds ((1-4th) i) is the number of deaths of children aged 1-4 years reported in the SRS in sub

district i.


Estimated results Results of the indicator estimates including the value of the standard error, 95% confidence

intervals and relative standard error (%) are shown in Table 1.

Tabel 1. Estimated Mortality Indicator Results, SRS 2014

Est SE 95% CI RSE

CDR Unadjusted 4.53 0.19 4.16 4.90 4.2%

Adjusted 7.48 0.31 6.87 8.09 4.1%

MMR Unadjusted 128.35 13.16 102.32 154.38 10.3%

Adjusted 244.64 26.20 192.79 296.49 10.7%

NMR Unadjusted 6.86 0.53 5.82 7.90 7.7%

Adjusted 12.88 1.10 10.70 15.07 8.5%

ENMR Unadjusted 5.59 0.44 4.71 6.46 7.9%

Adjusted 10.59 0.98 8.65 12.53 9.3%

IMR Unadjusted 9.95 0.73 8.50 11.40 7.3%

Adjusted 18.64 1.50 15.68 21.60 8.0%

U5MR Unadjusted 12.17 0.87 10.44 13.90 7.1%

Adjusted 22.93 1.85 19.26 26.60 8.1%

CMR Unadjusted 2.22 0.25 1.72 2.73 11.3% Adjusted 4.30 0.55 3.20 5.39 12.8%


APPENDIX 1

ESTIMATION OF THE TOTAL POPULATION IN 2014 BASED ON MINISTRY OF

HOME AFFAIRS (ADMINDUK) DATA IN SELECTED SUBDISTRICTS WITH

TRIMMED WEIGHT

Age Group Male Female Total

0-4 7,524,998 6,645,404 14,170,402 5-9 9,339,694 8,431,501 17,771,195 10-14 9,826,596 8,907,990 18,734,586 15-19 11,114,881 10,436,530 21,551,411 20-24 11,918,006 11,535,884 23,453,890 25-29 12,172,792 11,865,664 24,038,456 30-34 12,540,290 12,084,053 24,624,343

35-39 10,891,950 10,526,711 21,418,661 40-44 10,142,530 9,698,412 19,840,942 45-49 8,176,243 8,066,417 16,242,660 50-54 7,053,429 6,756,394 13,809,823 55-59 5,294,841 4,924,225 10,219,066 60-64 3,926,257 3,593,181 7,519,438 65+ 6,470,851 6,782,418 13,253,269

Total 126,393,358 120,254,784 246,648,142


APPENDIX 2

ESTIMATION OF THE TOTAL POPULATION IN 2014 BASED ON PROJECTION

RESULTS (BPS AND BAPPENAS)

Age group Male Female Total

0-4 12,301,392 11,785,386 24,086,778 5-9 11,857,284 11,252,246 23,109,530 10-14 11,448,373 10,911,854 22,360,227 15-19 11,237,841 10,786,863 22,024,704 20-24 10,768,431 10,583,932 21,352,363 25-29 10,398,169 10,318,093 20,716,262 30-34 10,150,247 10,280,665 20,430,912

35-39 9,802,553 9,784,546 19,587,099 40-44 9,054,191 8,950,497 18,004,688 45-49 7,949,128 7,918,231 15,867,359 50-54 6,650,671 6,663,076 13,313,747 55-59 5,319,575 5,198,516 10,518,091 60-64 3,804,761 3,714,074 7,518,835 65+ 5,972,572 7,301,619 13,274,191

Total 126,715,188 125,449,598 252,164,786


APPENDIX 3

ESTIMATION OF THE TOTAL POPULATION IN 2014 BASED ON SURVEY

RESULTS WITH SEX-AGE-SPECIFIC CELL WEIGHT ADJUSTMENT

Age group Male Female Total

0-4 12,352,988 11,710,785 24,063,773 5-9 12,683,173 11,990,420 24,673,593 10-14 12,353,039 11,702,632 24,055,671 15-19 11,242,861 10,913,607 22,156,468 20-24 10,473,241 10,634,551 21,107,792 25-29 11,260,873 11,352,327 22,613,200

30-34 10,538,536 10,504,231 21,042,767 35-39 9,890,464 9,745,526 19,635,990 40-44 8,815,564 8,719,190 17,534,754 45-49 7,449,203 7,450,030 14,899,233 50-54 6,213,368 6,054,348 12,267,716 55-59 4,660,893 4,303,449 8,964,342 60-64 3,100,533 3,328,979 6,429,512 65+ 5,680,450 7,039,523 12,719,973

Total 126,715,186 125,449,598 252,164,784


APPENDIX 4

LEVEL OF MORTALITY REPORTING COVERAGE OF 2010 POPULATION

CENSUS BY PROVINCE, METHOD AND SEX

Province BGB Preston-Cole

Male (%) Female (%) Male (%) Female (%)

Aceh

North Sumatera

West Sumatera

Riau

Jambi

South Sumatera

Bengkulu

Lampung

Bangka Belitung

Kepulauan Riau

Jakarta

West Java

Central Java

Yogyakarta

East Java

Banten

Bali

West Nusa Tenggara

East Nusa Tenggara

West Kalimantan

Central Kalimantan

South Kelimantan

East Kalimantan

North Sulawesi

Central Sulawesi

South Sulawesi

Southeast Sulawesi

Gorontalo

West Sukawesi

Maluku

North Maluku

West Papua

Papua

44

39

59

40

36

42

45

43

51

37

33

41

50

57

45

30

38

47

46

35

42

53

37

54

49

54

54

62

55

45

34

19

15

29

27

53

32

30

36

34

33

46

30

27

32

42

49

38

24

33

36

37

30

34

46

35

46

39

42

43

57

46

39

30

15

12

41

36

52

35

34

39

41

40

47

33

29

38

45

53

41

26

36

44

45

33

36

49

29

47

49

54

50

57

51

40

30

16

12

28

25

47

31

28

34

33

30

42

36

22

31

39

49

36

23

34

34

35

28

33

45

31

41

35

41

39

54

42

34

27

12

10

INDONESIA 44 37 41 35


ANNEX 4

INSTRUMENTS USED IN THE INDONESIAN SAMPLE REGISTRATION SYSTEM 2014

( )

RESPONDEN SETUJU DIWAWANCARAI : 1. SETUJU DIWAWANCARAI

2. MENOLAK DIWAWANCARA → AKHIRI

Nama Responden : ( ) Nama Saksi :

NO. TELEPON / HP ..............................................................................................................................................................................

INFORMED CONSENT

Selamat pagi/siang/sore/malam, Nama saya................................... dan saya bekerja di........................................ Kami sedang mengumpulkan data tentang penyebab

kematian di daerah ini. Kami sangat senang sekali apabila Bapak/Ibu dapat ikut berpartisipasi dalam kegiatan ini. Kami akan bertanya mengenai keadaan yang

menyebabkan kematian. Informasi apapun yang Bapak/Ibu berikan akan kami simpan dan dirahasiakan. Identitas Bapak/Ibu (responden) maupun

almarhum/ah.............................. tidak akan kami beri tahu kepada siapapun. Partisipasi untuk kegiatan ini adalah sukarela dan Bapak/Ibu dapat memilih untuk

bersedia menjawab sebagian pertanyaan atau tidak bersedia menjawab semuanya. Bapak/Ibu dapat menghentikan wawancara kapan saja tanpa ada konsekuensi.

Kami berharap Bapak/Ibu dapat ikut berpartisipasi dalam kegiatan ini, karena hal ini akan membantu pemerintah untuk meningkatkan pelayanan kesehatan

khususnya di daerah ini. Sekarang ini apakah Bapak/Ibu ingin bertanya mengenai tujuan dan isi dari wawancara ini? Bolehkah saya memulai wawancara ini

sekarang?

Tanda Tangan Responden : ................................................... Tanda Tangan Saksi : ...................................................

10. ALAMAT LENGKAP ALMARHUM/AH ............................................................................................................................................................................................................................................................

RT/RW/KELURAHAN/DESA .............................................................................................................................................................................................

............................................................................................................................................................................................................................................................

7. NAMA KEPALA RUMAH TANGGA.....................................................................................................................................................................................................................................................

8. NAMA RESPONDEN.....................................................................................................................................................................................................................................................

9. STATUS KEPENDUDUKAN ALMARHUM/AH 1. Penduduk 2. Bukan Penduduk

5. NOMOR KASUS KEMATIAN.....................................................................................................................................................................................................................................................

6. NAMA ALMARHUM/AH.....................................................................................................................................................................................................................................................

3. KECAMATAN.....................................................................................................................................................................................................................................................

4. KELURAHAN/DESA.....................................................................................................................................................................................................................................................

1.3 DATA DEMOGRAFI

1. PROVINSI......................................................................................................................................................................................................................................................

2. KABUPATEN.....................................................................................................................................................................................................................................................

2. TANGGAL ...................................

1. NAMA ...................................

1.2 KETERANGAN PENGAWAS/EDITOR

PENGAWAS/EDITOR EDITOR PUSAT KODE PENGENTRI

1 2 3

HASIL KUNJUNGAN :

1. Lengkap 2. RT Tidak ada dirumah 3. Ditunda 4. Ditolak

5. Tidak lengkap 6. Responden tidak dapat dijumpai 7. Lainnya (sebutkan) ...................................................................

5. JUMLAH KUNJUNGAN4. TANGGAL ................................... ...................................

5. WAKTU ................................... ...................................

0 1

4. HASIL KUNJUNGANRENCANA KUNJUNGAN BERIKUTNYA :

3. HASIL KUNJUNGAN* 3. TAHUN 2

2. NAMA PEWAWANCARA ................................... ................................... ................................... 2. BULAN

1. TANGGAL ................................... ................................... ................................... 1. TANGGAL

1. KUNJUNGAN WAWANCARA

1.1 KETERANGAN KUNJUNGAN 1 2 3 4. KUNJUNGAN AKHIR

Propinsi Kab/Kota Kecamatan Kel/Desa No. Urut Kasus

KUESIONER AUTOPSI VERBAL 1UNTUK KEMATIAN NEONATAL UMUR 0 – 28 HARI

ID/NOMOR REFERENSI KONTROL

TIDAK TAMAT SD _____________________________________2

TAMAT SD ___________________________________________3

TAMAT SLTP ______________________________________4

TAMAT SLTA __________________________________________5

TAMAT PT __________________________________________6

meninggal?

RUMAH SAKIT _____________________________________

3

6

8

2

RUMAH __________________________________________

LAINNYA .................................................................

TIDAK TAHU ____________________________________

(sebutkan)

LAKI-LAKI ________________________________________

PEREMPUAN ____________________________________

304 Berapa umur Neonatal (almahum/ah) saat

KODE 98 → JIKA TANGGAL DAN BULAN TIDAK DIKETAHUI

6

→ JIKA TAHUN TIDAK DIKETAHUI

2

1

8

1

302 Apa jenis kelaminnya? 1


LAKI-LAKI ________________________________________

PEREMPUAN ____________________________________2

3. KETERANGAN NEONATAL (ALMARHUM/AH) DAN TANGGAL/TEMPAT KEMATIAN

301

303

BULAN

Di mana Neonatal (Almarhum/ah) meninggal?

KODE 9998

305 Kapan Neonatal (Almarhum/ah) meninggal?

KODE 9998

TIDAK _______________________________________________

207

Siapa nama Neonatal (Almarhum/ah )?

Kapan Neonatal (Almaruhum/ah) lahir?

................................................................................................

→ JIKA TAHUN TIDAK DIKETAHUI

306 1

205 Apakah pendidikan terakhir Bapak/Ibu/Sdr/i? TIDAK SEKOLAH _____________________________________1

2

1

(sebutkan)

SAUDARA ___________________________________________

HUBUNGAN LAINNYA ...................................................

TIDAK ADA HUBUNGAN _____________________________

Apakah Bapak/Ibu/Sdr/i tinggal dengan Neonatal

(Almarhum/ah) pada saat menjelang kematiannya?

YA _______________________________________________

JAM _________________________________

HARI __________________________________

1

2

TANGGAL

BULAN

4

JAM

PERTANYAAN KATEGORI KODE LANJUT KENO.

2. KETERANGAN RESPONDEN

201

Umur Responden

Jenis Kelamin Responden204

2

AYAH _____________________________________________

IBU ________________________________________________

................................................................................................202 Nama Responden

Catatan waktu awal wawancara

Neonatal (Almahum/ah)?

MENIT

UMUR DALAM TAHUN203

FASILITAS KESEHATAN LAINNYA _________________________

TAHUN

206 Apakah hubungan Bapak/Ibu/Sdr/i dengan

TANGGAL

TAHUN


.......................................................................................................................................................................................................

4.

1.

2.

3.

4.

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

Dapatkah Bapak/Ibu/Sdr menceritakan tentang riwayat penyakit/kejadian yang menyebabkan

5. RIWAYAT KEHAMILAN IBU DARI NEONATAL (ALMARHUM/AH)

402

Saya ingin menanyakan tentang keadaan penyakit yang pernah diderita Almarhum/ah sebelum saat meninggalnya,

kejadian cedera atau kecelakaan yang pernah dialami, dan tanda dan gejala yang dialami oleh Almarhum/ah saat

sakitnya. Beberapa pertanyaan mungkin tidak berhubungan langsung dengan penyebab kematian Almarhum/ah. Kami

mengharap kesabaran anda untuk menjawab pertanyaan. Jawaban anda akan membantu kami untuk mendapatkan

kejelasan tanda dan gejala yang pernah dialami oleh Almarhum/ah saat sakitnya.

Penyebab kematian berdasarkan responden : ...............................................................................................................

kali ibu melahirkan, termasuk yang lahir mati.

506

4. PENJELASAN RESPONDEN TENTANG PENYAKIT/KEJADIAN YANG MENYEBABKAN KEMATIAN

401

8

(sebutkan) ...............................................................................................................

Mohon katakan jika Almarhum/ah mengalami penyakit seperti berikut :

TIDAK TAHU ______________________________9 8

TIDAK TAHU ______________________________9 8

BULAN ________________________________________________

KENCING MANIS/DIABETES

EPILEPSI/AYAN

PENYAKIT LAINNYA

504 Berapa minggu sebelum waktu yang seharusnya?

8

503

2seharusnya?

Apakah ibu melahirkan sebelum waktu yang 1

Y

Selama kehamilan apakah ibu mengalami

2 85.

8

2. 1 2

502 Berapa usia kehamilan saat Neonatal (Almarhum/ah)

1 2

JML KELAHIRAN TMSK LAHIR MATI ________501 Sebelum kelahiran Neonatal (Almarhum/ah), berapa

1.

505

10.

Perdarahan pervagina?

Keluar cairan vagina bau?

Wajah bengkak?3. 1 2

1 2 8

PERDARAHAN PER VAGINA

1 2 8

T TT

Tekanan darah tinggi?

Penyakit jantung?

Kencing manis / Diabetes?

Epilepsi/ayan?

8. 1 2

1.

2.

3.

5. 1

3.

mengalami penyakit seperti di bawah ini? Y T TT

Sakit kepala?

Pandangan kabur?

Kejang?

Demam?

Sakit perut hebat ? (bukan sakit persalinan)

4.

5.

6.

7.

8.

9.

SAKIT KEPALA

5. 1 2

2 81

Neonatal (Almarhum/ah) meninggal? ..................................................................................................................................

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

penyakit seperti di bawah ini?

TEKANAN DARAH TINGGI

PENYAKIT JANTUNG

dilahirkan?

YA _______________________________________________

TIDAK ___________________________________________

89

TIDAK TAHU _______________________________________

MINGGU ________________________________________________

TIDAK TAHU ______________________________

2

8

2. 1 2 8

1. 1

7. 1 2 8

6. 1 2 8

(sebutkan) ...............................................................................................................

Pucat dan sesak nafas

Penyakit lainnya?

4.

KELUAR CAIRAN VAGINA BAU

WAJAH BENGKAK

Selama 3 bulan terakhir kehamilan, apakah ibu

8

9.

1 82

KEJANG

DEMAM

SAKIT PERUT HEBAT

(BUKAN SAKIT PERSALINAN)

PUCAT DAN NAFAS CEPAT

PENYAKIT LAIN

8

8

1 2 8

505

505

10.

Apakah ada penyakit lainnya?

PANDANGAN KABUR


604 1

TIDAK TAHU ______________________________________

Urutan kelahiran keberapa Neonatal ini dari

saudara kembarnya?

PERTAMA ________________________________________

KEDUA __________________________________________2

508 1

603

507 Apakah Neonatal (Almarhum/ah) lahir tunggal

602

6. RIWAYAT PERSALINAN NEONATAL (ALMARHUM/AH)

601 01

02

03

04

05

06

96

98

(sebutkan)

TIDAK TAHU _____________________________________

2

3

Kapankah air ketuban pecah?

LAINNYA ...............................................................................................................

SEBELUM PERSALINAN DIMULAI ___________________

RUMAH SAKIT ___________________________________

PUSKESMAS/PUSTU _______________________________

RUMAH BERSALIN ________________________________

POLINDES ______________________________________

PRAKTEK BIDAN ____________________________________

RUMAH ______________________________________

Di manakah Neonatal (Almarhum/ah) dilahirkan?

Siapakah yang menolong persalinan?

608 Apakah penolong persalinan mendengarkan 1

607 1

2

Sejak kapankah bayi berhenti bergerak sewaktu

di dalam kandungan?

2

8

8

606 Apakah bayi sudah tidak bergerak sewaktu 1

605 1

2

Apakah air ketubannya berbau?

di dalam kandungan?

SEBELUM PERSALINAN DIMULAI _______________________

SAAT PERSALINAN __________________________________

TIDAK TAHU ______________________________________

YA _______________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

2

8TIDAK TAHU _______________________________________

denyut jantung janin selama proses persalinan? TIDAK ___________________________________________

6

8

3

8

Berapa jam setelah ketuban pecah bayi dilahirkan?

2

1

8

4

5

DOKTER ___________________________________________

8

2

1

≤ 12 JAM __________________________________________

8

8

LAINNYA .................................................................

> 12 - 24 JAM __________________________________________

> 24 JAM ____________________________________________

TIDAK TAHU ________________________________________

YA _______________________________________________

TIDAK ___________________________________________

1

(sebutkan)

DUKUN BERSALIN _______________________________________________

KELUARGA _____________________________________________

TIDAK TAHU ____________________________________________

3

TIDAK TAHU ______________________________________

SEWAKTU PERSALINAN ___________________________

KETIGA ATAU LEBIH _____________________________

TIDAK TAHU _________________________________

3

atau kembar? KEMBAR _________________________________________

KEMBAR TIGA ATAU LEBIH ________________________

2

TUNGGAL ________________________________________

BIDAN ______________________________________________________

PERAWAT _________________________________________________

601

601

608

608

610

610


610 Apakah ada perdarahan yang banyak saat 1

2

8

609 1

2

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

Apakah denyut jantung janin terdengar?

8

614 1

2

612 1

611

2

Apakah persalinan normal?

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

KURANG DARI 12 JAM _______________________________

12 - 23 JAM ________________________________________

24 JAM ATAU LEBIH __________________________________

TIDAK TAHU _________________________________________

persalinan dimulai?

Apakah ibu mengalami demam pada saat

persalinan dimulai?

8

3

1

2

8

1

2

8

613

Berapa lama proses persalinan?

(dari pertama his melahirkan)

7. KONDISI NEONATAL (ALMARHUM/AH) SESAAT SETELAH LAHIR

701 Bagaimanakah ukuran Neonatal (Almarhum/ah) 1

8

616

4

6

(sebutkan)

2

3

615 Bagian tubuh Neonatal manakah yang keluar 1

6

8

Apakah tali pusat keluar terlebih dahulu sebelum 1

2

8

(sebutkan)

KAKI __________________________________________________

TANGAN ______________________________________________

TIDAK TAHU _____________________________________________

SANGAT KECIL ____________________________________________

TIDAK TAHU _______________________________________

terlebih dahulu?

Neonatal (Almarhum/ah) lahir?

YA _______________________________________________

703

702 Apakah Neonatal (Almarhum/ah)

9

4

8

2

3

89

1

2

8

LEBIH KECIL DARI NORMAL _________________________

NORMAL ____________________________________________

LEBIH BESAR DARI NORMAL ____________________________

TIDAK TAHU ____________________________________________

MENGGAMBARKAN UMUR KEHAMILAN

Neonatal (Almarhum/ah) lahir?

TIDAK TAHU _______________________________________

Jenis persalinan? FORCEPS/VACUM ________________________________________

OPERASI SESAR ____________________________________

TIDAK ___________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

lahir kurang bulan?

615

615

LAINNYA .................................................................

LAINNYA .................................................................

704

704

1

2

BULAN ________________________________________

MINGGU ____________________________________

TIDAK TAHU _________________________________

KEPALA _____________________________________________

BOKONG ___________________________________________

saat lahir?

Pada usia kehamilan berapakah (bulan/minggu)


JIKA SEMUA JAWABAN 713, 715, 716 → "TIDAK",

PERIKSA JAWABAN DARI PERTANYAAN NO. 713, 715, 716, JIKA JAWABAN 713, 715, 716 → "SELAIN TIDAK"

704 Berapakah berat badan lahir Neonatal GRAM ________________________________

706 ...............................................................................................

709

708 Jika "YA" sebutkan dibagian tubuh mana tanda

705 Apakah tali pusat diberi sesuatu setelah 1

2

8

...............................................................................................

...............................................................................................

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

dilahirkan?

Jika diberikan sesuatu, sebutkan!

Apakah terdapat tanda cedera atau patah tulang

ketika Neonatal (Almarhum/ah) dilahirkan?

710

707

1

2

2

8

cedera atau patah tulang tersebut!

Apakah ditemukan tanda kelumpuhan?

1

2

8

1

cacat bawaan saat lahir?

712 1

4

6

2

3

Neonatal (Almarhum/ah)?

Bagaimana warna kulit Neonatal (Almarhum/ah)

waktu dilahirkan?

711 1

8

713 Apakah Neonatal (Almarhum/ah) sempat bernafas

setelah dilahirkan walaupun sebentar?

8

(sebutkan)

8

YA _______________________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

LAINNYA .................................................................

TIDAK TAHU __________________________________________

TIDAK TAHU _______________________________________

NORMAL ___________________________________________

PUCAT ____________________________________________

BIRU ______________________________________________

Kecacatan seperti apakah yang dimiliki

3

bantuan pernafasan?

717

716 Apakah Neonatal (Almarhum/ah) bergerak

sewaktu dilahirkan walaupun sebentar dan lemah?

715

714

1

2

8

1

2

8

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

Apakah Neonatal (Almarhum/ah) menangis

1

2

Apakah Neonatal (Almarhum/ah) mendapatkan

TIDAK ___________________________________________

8

1

2

8TIDAK TAHU _______________________________________

9 9 9

8

Apakah Neonatal (Almarhum/ah) memiliki

709

712

712

BENJOLAN/CACAT DI TULANG BELAKANG _______________

KEPALA SANGAT BESAR _________________________________

KEPALA SANGAT KECIL ______________________________

BIBIR DAN ATAU LANGIT-LANGIT SUMBING _______________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

709

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ____________________________

707

707TIDAK TAHU _______________________________________

sewaktu dilahirkan walaupun sebentar dan lemah?

2

801

(Almarhum/ah)?


Jenis cedera apa yang menyebabkan Neonatal

717 Jika Neonatal (Almarhum/ah) tidak menangis, tidak

bernafas dan tidak bergerak, apakah Neonatal

1

2

YA _______________________________________________

8

TIDAK TAHU _________________________________________

802 01

02

03

04

05

06

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

8. RIWAYAT CEDERA

801

718 1

2

8

1

2

8

Apakah Neonatal (Almarhum/ah) mengalami

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

Apakah kulit Neonatal (Almarhum/ah) mengalami

maserasi, menunjukkan tanda pembusukan?

cedera yang menyebabkan kematiannya? 804

804

803 1

2

8

1

2

8

YA _______________________________________________

TIDAK ___________________________________________

LAINNYA .................................................................

Sebutkan jenis binatang/serangga tersebut? ANJING ___________________________________________________

ULAR ________________________________________________

SERANGGA ____________________________________________

binatang/serangga sehingga meninggal?

903

9 89

902

8

1

2

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

(Almarhum/ah) lahir mulai menyusu atau

menghisap susu botol?

Apakah Neonatal (Almarhum/ah) berhenti

TIDAK TAHU ______________________________

96

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

TIDAK ___________________________________________

KEKERASAN ________________________________________

TIDAK TAHU

LAINNYA .................................................................

TIDAK TAHU _______________________________________

98

8

9. RIWAYAT PENYAKIT SEBELUM NEONATAL (ALMARHUM/AH) MENINGGAL

(Almarhum/ah) lahir mati (lahir sudah mati)?

Apakah cedera tersebut dilakukan oleh

(sebutkan)

901

901

orang lain dengan sengaja?

Apakah Neonatal (Almarhum/ah) digigit

JIKA JAWABAN 717 → "TIDAK"

PERIKSA JAWABAN DARI PERTANYAAN 717 UNTUK NEONATAL YANG LAHIR MATI : JIKA JAWABAN 717 → "YA" 1001

JAM 1

2

Berapa lama (jam/hari) setelah Neonatal

801

HARI

905

(Almarhum/ah) meninggal?

KECELAKAAN LALU LINTAS ________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

(SEBUTKAN)

901

3

6

805 1

2

1

2

8

804

menyusu atau menghisap susu botol?

Apakah Neonatal (Almarhum/ah) dapat

menyusu atau menghisap susu botol?

905

905

905

JATUH _________________________________________

TENGGELAM ______________________________________

KERACUNAN _____________________________________

KEBAKARAN ______________________________________


904

1

9

908

907 Berapa lama (hari) setelah dilahirkan Neonatal

1Apakah Neonatal (Almarhum/ah) mengalami kaku

906

2

8

1

2

8

905

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

9TIDAK TAHU ____________________________________

HARI ____________________________________

mengalami kejang?

YA _______________________________________________

8

911


1

9 8

YA _______________________________________________

909

2

8

1

2

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

dan badan melengkung ke belakang?

Apakah ubun-ubun Neonatal (Almarhum/ah)

menonjol?

(Almarhum/ah) mengalami ubun-ubun menonjol


913 1

2

8

8

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________


2

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

HARI _______________________________________

TIDAK TAHU ____________________________________9

penurunan kesadaran atau tidak memberikan

reaksi?

(Almarhum/ah) mengalami penurunan kesadaran

atau tidak memberikan reaksi?


demam?

915 Apakah Neonatal (Almarhum/ah) terasa dingin

9


1

2

8

8

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

HARI ____________________________________

TIDAK TAHU ____________________________________

ketika disentuh?

(Almarhum/ah) mengalami demam?

917

9


1

2

8

8

Apakah Neonatal (Almarhum/ah) pernah YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

mengalami batuk?

HARI ____________________________________

TIDAK TAHU ____________________________________(Almarhum/ah) terasa dingin ketika disentuh?

9


8

HARI ____________________________________

TIDAK TAHU ____________________________________mulai mengalami batuk?

911

911

913

913

915

915

917

917

919

919

HARI ____________________________________

TIDAK TAHU ____________________________________

Apakah Neonatal (Almarhum/ah)

8

Berapa lama (hari) setelah Neonatal (Almarhum/ah)

lahir berhenti menyusu atau menghisap botol?

Apakah Neonatal (Almarhum/ah)

mendapatkan ASI eksklusif?

TIDAK TAHU ____________________________________

HARI _______________________________________

(Almarhum/ah) mulai mengalami kejang?

tersebut?

908

908


HARI ____________________________________

TIDAK TAHU ____________________________________

Ketika diare paling parah, berapa kali

921

921

926

1

2

8


TIDAK ___________________________________________

TIDAK TAHU _______________________________________

921

9

920

8

1

2

8


TIDAK ___________________________________________

TIDAK TAHU _______________________________________

919

HARI ____________________________________

TIDAK TAHU ____________________________________

926

925

Apakah Neontal (Almarhum/ah) pernah

mengalami diare?

924

(Mengorok/mendengkur dan mengi)

923

(Almarhum/ah) mulai mengalami sulit bernafas? 9

922

1

2

8

1

2

8

1

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________Apakah saat bernafas, cuping hidung Neonatal

Apakah otot dinding dada bagian bawah Neonatal

(Almarhum/ah) tertarik ke dalam ketika bernafas?

Apakah nafas Neonatal (Almarhum/ah) berbunyi

Berapa lama (hari) setelah dilahirkan Neonatal

9


(Almarhum/ah) mengalami diare?

buang air besar dalam sehari?

HARI ____________________________________

TIDAK TAHU ____________________________________

926

8

2TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

(Almarhum/ah) terlihat kembang kempis?

8

930

930

929 1

2

8

Apakah ada darah dalam tinja?

9

928

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

9

931

930 Apakah Neonatal (Almarhum/ah) pernah

8

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

mengalami muntah?


(Almarhum/ah) mulai mengalami muntah?

HARI ____________________________________

TIDAK TAHU ____________________________________

2

8

933

933

933 Apakah perut Neonatal (Almarhum/ah)

9

932 Ketika muntah paling berat, berapa kali

2

8

8

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

muntah dalam sehari?

terlihat/teraba menggembung dan kencang?

JUMLAH ____________________________________

1

935

935

TIDAK TAHU ____________________________________

(Almarhum/ah) terlihat/teraba menggembung 9

934 Berapa lama (hari) setelah lahir perut Neonatal

dan kencang?

HARI ____________________________________

TIDAK TAHU ____________________________________

1

8

8

HARI ____________________________________

TIDAK TAHU ____________________________________

mengalami nafas cepat?

(Almarhum/ah) mulai mengalami nafas cepat?


mengalami sulit bernafas?

8

8

1

2

* TIRUKAN SUARANYA


pengobatan untuk penyakit terakhirnya sebelum

...............................................................................................

...............................................................................................

...............................................................................................

diberikan kepada Neonatal (Almarhum/ah) untuk

SALIN RESEP/CATATAN KWITANSI JIKA ADA

meninggal?

Bagaimana keadaan kesehatan Ibu sekarang?

935 Apakah pada tali pusat Neonatal (Almarhum/ah) 1

2

8

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

terdapat tanda kemerahan atau keluar cairan

yang berbau?

936 1

2

8

1

Apakah pada kulit Neonatal (alamrhum/ah)

Apakah telapak tangan/kaki Neonatal

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

terdapat bintik-bintik merah yang menonjol?

(Almarhum/ah) tampak kuning/pucat?1001

9

939

938

2

8

9 8

937

8

Berapa lama (hari) setelah lahir telapak tangan/kaki

Neonatal (Almarhum/ah) tampak kuning/pucat?

Berapa lama (hari) telapak tangan/kaki

Neonatal (Almarhum/ah) tampak kuning/pucat?

HARI ____________________________________

TIDAK TAHU ____________________________________

HARI ____________________________________

TIDAK TAHU ____________________________________

1001

1003

1002 1

2

8

1

10. KESEHATAN IBU DAN FAKTOR LAINNYA

1001 Berapa umur ibu ketika Neonatal

Apakah Ibu mendapatkan suntikan TT?

Apakah Ibu memeriksakan kehamilannya?

(Almarhum/ah) meninggal?9 8

1005

TIDAK TAHU ____________________________________

TAHUN ____________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

11. PENGOBATAN DAN PELAYANAN KESEHATAN PADA EPISODE SAKIT TERAKHIR

3

1005 1

2

1004

2

8

Berapa kali Ibu mendapatkan suntikan TT?

9 8

8

MENINGGAL __________________________________________

TIDAK TAHU _________________________________________

1005

JUMLAH ____________________________________

TIDAK TAHU ____________________________________

SEHAT __________________________________________________

SAKIT _____________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

penyakit yang menyebabkannya meninggal? ...............................................................................................

...............................................................................................

1102 Sebutkan jenis obat (pengobatan) apa saja yang

1101 Apakah Neonatal (Almarhum/ah) mendapat 1

2

8

...............................................................................................

...............................................................................................

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

1201

1201

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________


1203

1203

1301

1301

1306

meninggal?

tentang penyebab kematiannya? ...............................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

1.

2.

3.

Rumah?

Pengobatan Tradisional?

Puskesmas?

RUMAH

PENGOBATAN TRADISIONAL

PUSKESMAS

Klinik Swasta?

1103 Dimana saja Neonatal (Almarhum/ah) mendapatkan

3.

1 2 8

8

2.

1 2 8

pengobatan untuk sakit yang menyebabkannya Y T TT

1.

1 2

6.

1 2 85.

1 2 84.

1 2 84.

5.

6.

RS Pemerintah?

2 8

8

7.

1 2 87.

8.Apotik, Toko Obat, Warung?

Tempat Lain?

APOTIK, TOKO OBAT, WARUNG

TEMPAT LAIN

(sebutkan) ...............................................................................................

JUMLAH PERIKSA ____________________________________

TIDAK TAHU ____________________________________oleh petugas kesehatan?

1106 Apa yang dijelaskan oleh petugas kesehatan

1105 1

2

8

...............................................................................................

(Almarhum/ah) pernah mendapatkan pelayanan 9

1104 Sebelum meninggal, berapa kali Neonatal

Apakah petugas kesehatan menjelaskan

penyakit/penyebab kematiannya?

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

12. DATA YANG TERTULIS DARI SURAT KETERANGAN KEMATIAN

1201 Apakah Neonatal (Almarhum/ah) mempunyai 1

2

8

Surat Keterangan Kematian?

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

1

DARI SURAT KETERANGAN KEMATIAN

YA _______________________________________________

1202 (Bolehkan saya melihat akte kematian tersebut?)

SALIN TANGGAL, BULAN, DAN TAHUN KEMATIAN

1203 Apakah Neonatal (Almarhum/ah) memiliki akte

TANGGAL BULAN TAHUN

1303 SURAT IZIN PENGUBURAN (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM SURAT TERSEBUT)

..........................................................................................................................................................................................................................................

1204 (Bolehkan saya melihat akte kematian tersebut?)

SALIN TANGGAL, BULAN, DAN TAHUN

1302 SALINLAH SEMUA KETERANGAN MEDIS YANG MENDUKUNG DARI DUA PELAYANAN KESEHATAN TERAKHIR (JIKA LEBIH DARI

DUA) DAN CATAT TANGGAL KETERANGAN MEDIS TERSEBUT (CATAT INFORMASI MENGENAI IBU DAN NEONATAL)

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

13. KETERANGAN PENDUKUNG DARI CATATAN KESEHATAN LAINNYA

TAHUN

TIDAK ___________________________________________

1301 Apakah ada keterangan kesehatan pendukung

DIKELUARKANNYA AKTE KEMATIAN?

TANGGAL BULAN

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

Kematian yang dikeluarkan oleh Kantor Dinas

Kependudukan dan Catatan Sipil?

lainnya?

2

1

2

1201

1201

RS Swasta?

RS PEMERINTAH

KLINIK SWASTA

RS SWASTA

8.

1


..................................................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

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..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

(ALMARHUM/AH)) ..........................................................................................................................................................................................................................................

CATATAN PEWAWANCARA

DIISI SETELAH WAWANCARA SELESAI

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

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..................................................................................................................................................................................................................................................................

1305 BUKU KIA/KMS (JIKA ADA, SALINLAH INFORMASI YANG BERHUBUNGAN DENGAN KESEHATAN IBU DAN NEONATAL

..........................................................................................................................................................................................................................................

1304

HASIL VISUM TERSEBUT) ..........................................................................................................................................................................................................................................

1306 CATATAN WAKTU AKHIR WAWANCARA

..........................................................................................................................................................................................................................................

JAM

MENIT

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

HASIL PEMERIKSAAN VISUM/AUTOPSY FORENSIK (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

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..................................................................................................................................................................................................................................................................

14. RESUME DAN DIAGNOSA (Dibuat oleh Dokter)

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

NAMA DOKTER : ..........................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

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..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

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..................................................................................................................................................................................................................................................................

RESUME AUTOPSI VERBAL : ..........................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................



A. KEMATIAN UMUR 7 HARI KE ATAS SELANG WAKTU MULAI TERJADINYA PENYAKIT SAMPAI MENINGGAL

I. PENYEBAB KEMATIAN MENURUT DOKTER PUSKESMAS THN BLN HARI JAM ICD -10

disebabkan oleh

c.

....................................................................................................................................................................

disebabkan oleh

b.

....................................................................................................................................................................

a.

....................................................................................................................................................................

disebabkan oleh

d.

....................................................................................................................................................................

....................................................................................................................................................................

II. PENYAKIT/KONDISI LAIN YANG BERKONTRIBUSI

NAMUN TIDAK BERHUBUNGAN DENGAN I a-d

....................................................................................................................................................................

B. KEMATIAN UMUR 0 - 6 HARI SELANG WAKTU MULAI TERJADINYA PENYAKIT SAMPAI MENINGGAL

a. PENYEBAB UTAMA BAYI THN BLN HARI JAM ICD -10

....................................................................................................................................................................

NAMA DOKTER :.....................................................................................................TANDA TANGAN DOKTER : .....................................................................................................

d. PENYEBAB LAIN IBU

....................................................................................................................................................................

TANGGAL DIAGNOSIS :.....................................................................................................

c. PENYEBAB UTAMA IBU

....................................................................................................................................................................

b. PENYEBAB LAIN BAYI

....................................................................................................................................................................

( )




NO. TELEPON / HP ..............................................................................................................................................................................

INFORMED CONSENT








sekarang?




............................................................................................................................................................................................................................................................


8. NAMA RESPONDEN.....................................................................................................................................................................................................................................................



6. NAMA ALMARHUM/AH.....................................................................................................................................................................................................................................................

3. KECAMATAN.....................................................................................................................................................................................................................................................

4. KELURAHAN/DESA.....................................................................................................................................................................................................................................................

1.3 DATA DEMOGRAFI

1. PROVINSI......................................................................................................................................................................................................................................................

2. KABUPATEN.....................................................................................................................................................................................................................................................

2. TANGGAL ...................................

1. NAMA ...................................



1 2 3

HASIL KUNJUNGAN :




5. WAKTU ................................... ...................................

0 1




1. TANGGAL ................................... ................................... ................................... 1. TANGGAL




KUESIONER AUTOPSI VERBAL 2UNTUK KEMATIAN ANAK UMUR 29 HARI - 14 TAHUN


205 Apakah pendidikan terakhir Bapak/Ibu/Sdr/i? TIDAK SEKOLAH _____________________________________1

TIDAK TAMAT SD _____________________________________2

TAMAT SD ___________________________________________3

TAMAT SLTP ______________________________________4

TAMAT SLTA __________________________________________5

TAMAT PT __________________________________________6

SUAMI/ISTRI ___________________________________________3

NO.

3. KETERANGAN ANAK (ALMARHUM/AH) DAN TANGGAL/TEMPAT KEMATIAN

2

1Apakah Pendidikan tertinggi Anak (Almarhum/ah)?

KODE 98 → JIKA TANGGAL DAN BULAN TIDAK DIKETAHUI BULAN

KODE 9998 → JIKA TAHUN TIDAK DIKETAHUI

4

TIDAK TAMAT SD ___________________________________

TAMAT SD ________________________________________

TAMAT SMP ________________________________________

Apakah Anak (Almarhum/ah) bekerja?

3

8TIDAK TAHU ______________________________________

1

(Almahum/ah)?IBU ________________________________________________2

SAUDARA ___________________________________________4

HUBUNGAN LAINNYA ...................................................6

204

206

207

301

302

303

304

305

306

Berapa umur Anak (Almarhum/ah) saat meninggal?

JIKA Anak UMUR < 5 TAHUN, TULIS DALAM BULAN

PERTANYAAN KATEGORI KODE LANJUT KE


MENIT

202 Nama Responden ................................................................................................

203 Umur Responden UMUR DALAM TAHUN

201 Catatan waktu awal wawancara JAM

Jenis Kelamin Responden LAKI-LAKI ________________________________________1

PEREMPUAN ____________________________________2

2

UMUR DALAM BULAN _________________________________1

UMUR DALAM TAHUN __________________________________2

YA _______________________________________________

TIDAK ___________________________________________

TIDAK SEKOLAH ___________________________________

Apakah hubungan Bapak/Ibu/Sdr/I dengan Anak AYAH _____________________________________________1

(sebutkan)

TIDAK ADA HUBUNGAN _____________________________8

Apakah Bapak/Ibu/Sdr/I tinggal dengan Anak YA _______________________________________________1

TAHUN

Apa jenis kelaminnya? LAKI-LAKI ________________________________________1

PEREMPUAN ____________________________________2

Kapan Anak (Almaruhum/ah) lahir? TANGGAL

(Almarhum/ah) pada saat menjelang kematiannya? TIDAK _______________________________________________2

Siapa nama Anak (Almarhum/ah)? ................................................................................................

NO. PERTANYAAN KATEGORI KODE LANJUT KE

(untuk umur > 10 tahun)






(Almarhum/ah) meninggal? ..................................................................................................................................

2

8


8

1

Apakah Anak (Almarhum/ah) menderita asma?

Apakah Anak (Almarhum/ah) menderita kencing

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

2

402

501

502

503

504

5. RIWAYAT PENYAKIT/MEDIS ANAK (ALMARHUM/AH) SEBELUMNYA

Penyebab kematian berdasarkan responden : ...............................................................................................................

1

Di mana Anak (Almarhum/ah) meninggal?

2

3

FASILITAS KESEHATAN LAINNYA _________________________

RUMAH __________________________________________

LAINNYA .................................................................

TIDAK TAHU ____________________________________

(sebutkan)

1



BULAN

TAHUN

RUMAH SAKIT _____________________________________

8

Kapan Anak (Almarhum/ah) meninggal?

4

5

307

308

2

3

Status perkawinan Anak (Almarhum/ah)?

MENIKAH ____________________________________

CERAI HIDUP ____________________________________

CERAI MATI ____________________________________

HIDUP BERPISAH ____________________________________

TIDAK TAHU ____________________________________

TANGGAL

BELUM MENIKAH ____________________________________


Dapatkah Bapak/Ibu/Sdr menceritakan tentang riwayat penyakit/kejadian yang menyebabkan Anak

6

8

Apakah Anak (Almarhum/ah) menderita penyakit

jantung?

.......................................................................................................................................................................................................

1

2

309

401

8

1

epilepsi/ayan?

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

8

Apakah Anak (Almarhum/ah) menderita

1

manis/diabetes? TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

2


603

A

604

605

605

2

YA _______________________________________________Apakah Anak (Almarhum/ah) menderita 505

506

507

508

509

510

2

8

1

2

8

malnutrisi/kurang gizi? TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

Apakah Anak (Almarhum/ah) menderita kanker?

YA _______________________________________________

JENIS .....................................................................Sebutkan jenis dan lokasi kanker?

Apakah Anak (Almarhum/ah) menderita

508

508

TIDAK TAHU _______________________________________

1

2

8

1

2

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

LOKASI .....................................................................

601

601

2

A

8 A

6. RIWAYAT CEDERA

1

05

06

03

04

01

02

..........................................................................................................................................

Sebutkan jenis diagnosis penyakit lainnya yang

Apakah Anak (Almarhum/ah) mengalami

Jenis cedera apa yang menyebabkan Anak

TIDAK ___________________________________________

KEBAKARAN ____________________________________________________________

KEKERASAN ____________________________________________________________

YA _______________________________________________

511

601

602

JATUH ____________________________________________________________

TENGGELAM ____________________________________________________________

KERACUNAN ____________________________________________________________

TIDAK TAHU _______________________________________

8

bunuh diri?

serangga sehingga meninggal?

1

2

96

(sebutkan)

98

Apakah menurut anda Anak (Almarhum/ah) 1

8

JIKA 10 TAHUN ATAU LEBIH


PERIKSA JAWABAN DARI PERTANYAAN 304 UNTUK USIA KEMATIAN ANAK :

B

8 B

2

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

LAINNYA .....................................................................

YA _______________________________________________

TIDAK ___________________________________________

YA _______________________________________________

JIKA KURANG 10 TAHUN

Apakah Anak (Almarhum/ah) digigit binatang/ 1

Apakah Anak (Almarhum/ah) menderita HIV/AIDS?

Apakah Anak (Almarhum/ah) menderita atau

1

TIDAK TAHU ____________________________________________________________

didiagnosis penyakit lain?

diderita Anak (Almarhum/ah)?

cedera yang menyebabkan kematiannya?

NAMA PENYAKIT .....................................................................

(Almarhum/ah) meninggal?


KECELAKAAN LALU LINTAS ______________________________

2

8

1YA _______________________________________________

TIDAK ___________________________________________

tuberkulosis?

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK TAHU _______________________________________

604


801

704

704

801

801

808

808

606

B

701

702

703

704

705

706

801

802

803

8. KEADAAN IBU DAN GEJALA YANG DITEMUKAN PADA PERIODE TERAKHIR SAKITNYA ANAK (ALMARHUM/AH)

Berapa lama (hari) sebelum meninggal Bayi

6

8

1

2

Apakah pada saat lahir ukuran Bayi (Almarhum/ah) 1

2

Sebutkan jenis binatang/serangga tersebut!

7. GEJALA DAN TANDA YANG DITEMUKAN PADA PERIODE TERAKHIR SAKITNYA BAYI (ALMARHUM/AH)

JIKA KURANG 1 TAHUN

804

8

2

8

Pada usia kehamilan berapakah (bulan/minggu)

1

9 8

Apakah Anak (Almarhum/ah) mengalami demam?

BULAN ________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

9 8

8

lebih kecil dari normal?

YA _______________________________________________

TIDAK ___________________________________________

ANJING _____________________________________________

ULAR ______________________________________________

SERANGGA _________________________________________

LAINNYA .................................................................

TIDAK TAHU _________________________________________

(sebutkan)

PERIKSA JAWABAN DARI PERTANYAAN 304 UNTUK USIA KEMATIAN ANAK : JIKA 1 TAHUN LEBIH

3

1

2

9 8

Apakah Bayi (Almarhum/ah) tumbuh dengan normal? 1

Apakah Bayi (Almarhum/ah) lahir kurang bulan?

9

Bayi (Almarhum/ah) lahir?

MENGGAMBARKAN UMUR KEHAMILAN

1

MINGGU ____________________________________2

TIDAK TAHU _________________________________

8

3

8

Berapa lama (hari/bulan) Anak (Almarhum/ah)

1

2

Apakah ubun-ubun Bayi (Almarhum/ah) menonjol?

TIDAK TAHU _______________________________________

YA _______________________________________________

Bagaimana keadaan kesehatan ibu sekarang?

menderita sakit sebelum meninggal?

HARI

TIDAK TAHU

SEHAT ______________________________________________

SAKIT __________________________________________________

MENINGGAL _______________________________________________

TIDAK TAHU _________________________________________________

(Almarhum/ah) mengalami ubun-ubun menonjol

tersebut?

1

2TIDAK ___________________________________________


9 9 8

2

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

mengalami demam?BULAN ________________________________________2

TIDAK TAHU _________________________________

HARI ________________________________________1

BULAN ________________________________________2

TIDAK TAHU _________________________________

HARI ________________________________________1

TIDAK TAHU _______________________________________

9

YA _______________________________________________

701

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________


812

812

818

818

820

820

818

818

sulit bernafas?

819

813

814

815

816

817

818

805

806

807

808

809

810

811

812

YA _______________________________________________Apakah demamnya tinggi?

8


1

2

2

8

Apakah demamnya terus menerus atau hilang

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

timbul?

mengigil?

TERUS-MENERUS ____________________________________________

HILANG TIMBUL _______________________________________

TIDAK TAHU __________________________________________

8

Apakah Anak (Almarhum/ah) mengalami batuk? 1

2

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

9 8

HARI ___________________________________________

TIDAK TAHU _________________________________

8

1

2

2

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

1

batuk?

Apakah batuknya parah?

Berapa lama (hari) Anak (Almarhum/ah) mengalami

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

nafas cepat?

nafas cepat?

HARI ___________________________________________

TIDAK TAHU _________________________________

1

2

8

2

8

Apakah Anak (Almarhum/ah) muntah setelah batuk?

Apakah Anak (Almarhum/ah) pernah mengalami

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

9 8

1

8



9 8

1

2

8

1

2

Apakah nafas Anak (Almarhum/ah) berbunyi YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________


Apakah otot dinding dada bagian bawah Anak

HARI ___________________________________________

9 8

1

otot-otot dinding dada bagian bawah tertarik

ke dalam ketika bernafas?

HARI ___________________________________________

TIDAK TAHU _________________________________

YA _______________________________________________

sulit bernafas?


(Almarhum/ah) tertarik ke dalam ketika bernafas? TIDAK ___________________________________________

TIDAK TAHU _______________________________________

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

(Almarhum/ah) terlihat kembang kempis? 2

YA _______________________________________________

mengorok/mendengkur/mengi?

* TIRUKAN SUARANYA

Apakah saat bernafas cuping hidung Anak

8

2

1

1

TIDAK TAHU _________________________________


820

821

822

823

824

825

826

827

828

829

830

831

832

833

834

nyeri perut?

Apakah Anak (Almarhum/ah) pernah mengalami YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

diare?

824

824

9 8

9 8

Ketika diare paling parah, berapa kali buang air


diare?

besar dalam sehari?

JUMLAH ___________________________________________

TIDAK TAHU _________________________________

TIDAK TAHU _________________________________

8

Berapa lama (hari) Anak (Almarhum/ah)

mengalami muntah?

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

1

2

8

1

2


muntah?

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

Apakah ada darah dalam tinja?

827

827

HARI ___________________________________________

dalam sehari?9 8

Apakah Anak (Almarhum/ah) mengalami YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

JUMLAH ___________________________________________

TIDAK TAHU _________________________________

9 8

Ketika muntah paling berat, berapa kali muntah

830

830

TIDAK TAHU _________________________________

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

834

834

9 8

Apakah nyeri perutnya hebat? 1


9

YA _______________________________________________

mengalami nyeri perut?

HARI ________________________________________1

BULAN ________________________________________2

TIDAK TAHU _________________________________

BULAN ________________________________________2

TIDAK TAHU _________________________________

HARI ________________________________________

8

Berapa lama perut Anak (Almarhum/ah) terlihat/

kembung/bengkak dan kencang?

teraba kembung atau kencang?

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

Apakah perut Anak (Almarhum/ah) terlihat/teraba 1

2

lebih? 8

2tidak BAB (Buang Air Besar) selama satu hari atau TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

836

836

8

9 8

1Apakah proses terjadinya penggembungan perut

tersebut terjadi dalam hitungan hari atau hitungan

bulan?

9

CEPAT DALAM HITUNGAN HARI _________________________

BERTAHAP DALAM HITUNGAN BULAN ___________________

TIDAK TAHU _________________________________________

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

Apakah ada benjolan di perut Anak (Almarhum/ah)? 1

2

1

HARI ___________________________________________

2

8

1

2

8

1

2

Apakah Anak (Almarhum/ah) pernah mengalami 1YA _______________________________________________

2


kaku kuduk?

838

839

840

841

842

843

844

845

846

847

835

836

837

839

839

Berapa lama (hari/bulan) ada benjolan di perut

Anak (Almarhum/ah)?

HARI ________________________________________1

BULAN ________________________________________2


9

YA _______________________________________________

mengeluh sakit kepala?

Apakah sakit kepalanya berat?

HARI ________________________________________1

BULAN ________________________________________2

TIDAK TAHU _________________________________

8

9 8

1Apakah Anak (Almarhum/ah) mengalami sakit

9

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

kepala?

TIDAK TAHU _________________________________

2

8

Apakah Anak (Almarhum/ah) mengalami kaku

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

8

841

841

844

844

kesadaran atau tidak memberikan reaksi?

9 8

1

Apakah Anak (Almarhum/ah) mengalami penurunan 1

HARI ___________________________________________

TIDAK TAHU _________________________________

8

8


TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

kuduk?2

mengalami kejang?

HARI ________________________________________1

BULAN ________________________________________2

846

846

HARI ___________________________________________

TIDAK TAHU _________________________________

TIBA-TIBA __________________________________________

CEPAT DALAM SEHARI ______________________________________

PERLAHAN DALAM BEBERAPA HARI _________________________

TIDAK TAHU ______________________________________________


Apakah proses penurunan kesadaran terjadi secara

2

9 8

1Apakah Anak (Almarhum/ah) menderita

9

2

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

kelumpuhan pada tungkai/kaki?

TIDAK TAHU _________________________________

HARI ________________________________________1

849

849


9 8TIDAK TAHU _________________________________


9

mengalami kelumpuhan pada tungkai/kaki?BULAN ________________________________________2

3

1

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

9 8

1

2

tiba-tiba, cepat dalam sehari atau perlahan dalam

Apakah Anak (Almarhum/ah) mengalami kejang? YA _______________________________________________

beberapa hari?

penurunan kesadaran atau tidak memberikan reaksi?9 8

2

1

8

2

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________


861

861

856

857

858

859

860

855

854

9

2

Apakah ada perdarahan keluar dari hidung,


HARI ________________________________________1

BULAN ________________________________________2

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK TAHU _______________________________________

848

849

850

851

852

853

Apakah ada perubahan jumlah air seni yang

tiba-tiba, dalam sehari atau perlahan dalam

beberapa hari?

YA _______________________________________________

1

8

CEPAT DALAM SEHARI ______________________________________

TIBA-TIBA __________________________________________Apakah kelumpuhan pada kaki terjadi secara

2 852

852

9 8

Berapa lama (hari/bulan) perubahan jumlah air seni

tersebut dialami Anak (Almarhum/ah)?

Berapa banyak jumlah air seni yang dikeluarkan

Anak (Almarhum/ah) dalam sehari?

dikeluarkan Anak (Almarhum/ah) dalam sehari?

8

Dimana lokasi bintik-bintik merah tersebut? Y T TT

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

PERLAHAN DALAM BEBERAPA HARI _________________________

TIDAK TAHU ______________________________________________

HARI ________________________________________1

BULAN ________________________________________2

TIDAK TAHU _________________________________

1

8

1


Selama sakit yang menyebabkan kematiannya,

apakah Anak (alamarhum/ah) menderita

bintik-bintik merah (ruam) di kulit?

TIDAK TAHU _________________________________

TERLALU BANYAK _________________________________________

TERLALU SEDIKIT __________________________________________

TIDAK TAHU _______________________________________

TIDAK ADA AIR SENI SAMA SEKALI ______________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

HARI ___________________________________________

2

3

856

856

2

8

1

2

3

8


1

2

1 2 83.

Seperti apa bentuk bintik-bintik merah (ruam)

tersebut?

LENGAN DAN KAKI3.

RUAM CAMPAK ____________________________________________

RUAM BERISI CAIRAN BENING ___________________________

RUAM BERISI PUS (NANAH) _______________________________

TIDAK TAHU _________________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

Lengan dan kaki?

mata merah?

8

1

9 8

1Apakah Anak (Almarhum/ah) terlihat sangat kurus?

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

TIDAK TAHU _________________________________

YA _______________________________________________

8


9

TIDAK ___________________________________________

mulut atau anus?

penurunan berat badan?

mengalami penurunan berat badan?

2

8

Badan? 8

1 21.

bintik-bintik merah (ruam) di kulit?

MUKAMuka?

2

3

8

BADAN 1 2

1

1

2

2.

1.

2.

9 8

8


863

863

866

866

869

869

871

871

873

873

861

862

863

864

865

866

869

870

871

872

868

9

9

9

8

1

Muka?

Sendi?

MUKA

SENDI

1.

2.

1.

2. 1 2 8

1

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

1

2


Apakah ada luka/bercak putih di lidah atau

867

HARI ___________________________________________

TIDAK TAHU _________________________________

9TIDAK TAHU _________________________________


mengalami pembengkakan tersebut?

luka/bercak putih pada lidah atau mulut?

mulut Anak (Almarhum/ah)?

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

Anak (Almarhum/ah)?

9 8

1Apakah terdapat pembengkakan pada bagian tubuh

2

3. 1 2 8Pergelangan Kaki?

Seluruh Tubuh?

Tempat Lain?

PERGELANGAN KAKI

SELURUH TUBUH

TEMPAT LAIN

3.

4.

5.

4.

Dimana lokasi pembengkakan tersebut? Y T TT

Apakah ada benjolan kelenjar getah bening

(kelenjar leher, ketiak, sela paha) di tubuh

Anak (alamarhum/ah) ?

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

1. 1 2 8

9 8

Y T TT

5. 1 2 8

seperti rambut jagung?

2

8

Berapa lama (hari/bulan) bagian putih mata Anak

TIDAK ___________________________________________

Apakah bagian putih mata Anak (Almarhum/ah) 1

4. 1 2Tempat Lain?

berubah menjadi kuning?

1

8

9 8atau kekuningan ?

(Almarhum/ah) menjadi kuning?

YA _______________________________________________


mengalami rambut kemerah-merahan

8

9 8

Apakah rambut Anak (Almarhum/ah) berubah

kemerah-merahan atau kekuningan

YA _______________________________________________

3. 1 2 8

Dimana lokasi benjolan kelenjar getah bening tersebut?

mengalami benjolan kelenjar getah bening tersebut?


Leher?

HARI ________________________________________

2 8

HARI ________________________________________1

BULAN ________________________________________

2. 1 2 8Ketiak?

Selangkangan?

2

TIDAK TAHU _______________________________________

2

(sebutkan) ..........................................................................

9 8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

2

8

1

1 2 8

YA _______________________________________________

BULAN ________________________________________2

TIDAK TAHU _________________________________

HARI ________________________________________1

BULAN ________________________________________2

TIDAK TAHU _________________________________

HARI ________________________________________1

BULAN ________________________________________2

TIDAK TAHU _________________________________

1. LEHER

2. KETIAK

3. SELANGKANGAN

4. TEMPAT LAIN

(sebutkan) ..........................................................................


875

875

901

901

909

873

874

875

876

901

902

903

904

905

906

907

(lemah/kurang darah ) atau terlihat pucat pada

telapak tangan,mata atau bantalan kuku?

Berapa lama (hari) Anak (Almarhum/ah)

terlihat pucat?

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

HARI ___________________________________________

1

campak?

2

Apakah Anak (Almarhum/ah) kelihatan pucat YA _______________________________________________


YA _______________________________________________

TIDAK TAHU _________________________________


9 8

Sebutkan jenis obat (pengobatan) apa saja yang ...............................................................................................

909

8

9 8

1YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

TIDAK TAHU _________________________________

HARI ___________________________________________

Apakah mata Anak (Almarhum/ah) cekung?

mata cekung?

2

Apakah Anak (Almarhum/ah) pernah diimunisasi 1

SALIN RESEP/CATATAN KUITANSI JIKA ADA

untuk penyakit terakhirnya sebelum meninggal?

diberikan kepada Anak (Almarhum/ah) untuk

penyakit yang menyebabkannya meninggal?

1

2

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________8

4.

2.

1 2 83.

1

1 2 8

pemberian cairan melalui infus?

Transfusi darah?

Pemberian makanan/obat dengan selang

yang dipasang melalui hidung (NGT)?

2

Apakah Anak (Almarhum/ah) mendapat pengobatan

Pengobatan Tradisional?

Puskesmas?

PENGOBATAN TRADISIONAL

PUSKESMAS

1.

pengobatan untuk sakit yang menyebabkannya

meninggal?1

8

Rehidrasi oral (minum oralit) dan atau

Dimana saja Anak (Almarhum/ah) mendapatkan

3.

2.

Jenis pengobatan apa saja yang diterima?Y T TT

1.

1 2

8

1 2

2

PENGOBATAN LAINNYA

1.

2.

Y T TT

1 2 87.

1

Jenis pengobatan lainnya? (sebutkan) ..........................................................................

1 2 85.

1 2 8

RS Pemerintah?

Klinik Swasta?

RS Swasta?

RS PEMERINTAH

KLINIK SWASTA

RS SWASTA

4.

5.

6.

2 83.

1 2 84.

2.1

8

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

9 8

2 88.

Sebelum meninggal, berapa kali Anak

8

909

909

penyakit/penyebab kematiannya?

JUMLAH PERIKSA _______________________________

TIDAK TAHU _________________________________

Apakah petugas kesehatan menjelaskan

TEMPAT LAINNYA8.

(sebutkan) ..........................................................................

Rumah?RUMAH1.

(Almarhum/ah) pernah mendapatkan pelayanan

oleh petugas kesehatan?

Tempat Lain?

Apotik, Toko Obat, Warung?

6.

1YA _______________________________________________

2

...............................................................................................

...............................................................................................

...............................................................................................

...............................................................................................

2 8

8

3.

4.

APOTIK, TOKO OBAT, WARUNG7.

ORALIT/INFUS CAIRAN

TRANSFUSI DARAH

NGT


1003

1101

1101

1106

1003

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

1101

1102

1103

1001


2

8

908

909

910

911

1002

1003

1004

2

8

8

Surat Keterangan Kematian?

...............................................................................................

YA _______________________________________________


Apakah ada keterangan kesehatan pendukung 1

2

SALINLAH SEMUA KETERANGAN MEDIS YANG MENDUKUNG DARI DUA PELAYANAN KESEHATAN TERAKHIR (JIKA LEBIH DARI

DUA) DAN CATAT TANGGAL KETERANGAN MEDIS TERSEBUT (CATAT INFORMASI MENGENAI IBU DAN ANAK)

SURAT IZIN PENGUBURAN (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM SURAT TERSEBUT)

..........................................................................................................................................................................................................................................

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

Apakah Anak (Almarhum/ah) mempunyai 1

lainnya?


TANGGAL BULAN TAHUN

Apa yang dijelaskan oleh petugas kesehatan tentang

YA _______________________________________________

penyebab kematiannya?

Apakah Anak (Almarhum/ah) menjalani operasi

Bagian tubuh mana yang dioperasi?

TIDAK TAHU _________________________________

1

...............................................................................................

...............................................................................................

...............................................................................................

1

1001

1001

(Bolehkan saya melihat akte kematian tersebut?)TANGGAL BULAN TAHUN

YA _______________________________________________

TIDAK ___________________________________________

TIDAK TAHU _______________________________________

PERUT ___________________________________________

DADA ___________________________________________________

KEPALA ______________________________________________

TIDAK TAHU ____________________________________________

2

LAINNYA ...............................................................................................

(sebutkan)

Berapa lama (hari) sebelum meninggal operasi

TIDAK ___________________________________________

Kematian yang dikeluarkan oleh Kantor Dinas

Kependudukan dan Catatan Sipil?

6

8

SALIN TANGGAL, BULAN, DAN TAHUN KEMATIAN


Apakah Anak (Almarhum/ah) memiliki Akte 1

..........................................................................................................................................................................................................................................

untuk pengobatan penyakitnya?

HARI ___________________________________________

TIDAK TAHU _______________________________________

2

3

9 8

TIDAK ___________________________________________

(Bolehkan saya melihat akte kematian tersebut?)


..........................................................................................................................................................................................................................................

tersebut dilakukan?

YA _______________________________________________


..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

CATATAN PEWAWANCARA


..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

1104

1105

1106

..........................................................................................................................................................................................................................................

CATATAN WAKTU AKHIR WAWANCARA

HASIL PEMERIKSAAN VISUM/AUTOPSY FORENSIK (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM

HASIL VISUM TERSEBUT)

..........................................................................................................................................................................................................................................

BUKU KIA/KMS (SALINLAH INFORMASI YANG BERHUBUNGAN DENGAN KESEHATAN IBU DAN ANAK (ALMARHUM/AH))

JAM

MENIT

..........................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................



NAMA DOKTER : ..........................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

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..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

NAMA DOKTER :.....................................................................................................TANDA TANGAN DOKTER : .....................................................................................................

....................................................................................................................................................................

....................................................................................................................................................................


disebabkan oleh

d.

....................................................................................................................................................................



disebabkan oleh

c.

....................................................................................................................................................................

disebabkan oleh

b.

....................................................................................................................................................................

a.

....................................................................................................................................................................

SELANG WAKTU MULAI TERJADINYA PENYAKIT SAMPAI MENINGGALI. PENYEBAB KEMATIAN MENURUT DOKTER PUSKESMAS

THN BLN HARI JAM ICD -10



( )




NO. TELEPON / HP ..............................................................................................................................................................................

INFORMED CONSENT








sekarang?




............................................................................................................................................................................................................................................................


8. NAMA RESPONDEN.....................................................................................................................................................................................................................................................



6. NAMA ALMARHUM/AH.....................................................................................................................................................................................................................................................

3. KECAMATAN.....................................................................................................................................................................................................................................................

4. KELURAHAN/DESA.....................................................................................................................................................................................................................................................

1.3 DATA DEMOGRAFI

1. PROVINSI......................................................................................................................................................................................................................................................

2. KABUPATEN.....................................................................................................................................................................................................................................................

2. TANGGAL ...................................

1. NAMA ...................................



1 2 3

HASIL KUNJUNGAN :




5. WAKTU ................................... ...................................

0 1




1. TANGGAL ................................... ................................... ................................... 1. TANGGAL




KUESIONER AUTOPSI VERBAL 3UNTUK KEMATIAN UMUR DIATAS 15 TAHUN


1

`

IBU _______________________________________________

SAUDARA _______________________________________

HUBUNGAN LAINNYA ..........................................................................

Berapa umur Almarhum/ah saat meninggal?

Apakah pekerjaan utama Almarhum/ah?

BULAN

TAHUN

Kapan Almarhum/ah lahir?

(sebutkan)

TIDAK ADA HUBUNGAN ___________________________

almahum/ah?

PEREMPUAN _______________________________

8

6

Apakah Bapak/Ibu/Sdr/i tinggal dengan almahum/ah 1

2pada saat menjelang kematiannya?

YA _________________________________________________

SUAMI/ISTRI _______________________________________3

302 Apa jenis kelaminnya? 1

2

UMUR DALAM TAHUN

TIDAK BEKERJA ________________________________

08

LAINNYA ..........................................................................

LAKI-LAKI _________________________________________

TANGGAL

304

303

→ JIKA TAHUN TIDAK DIKETAHUIKODE 9998

3. KETERANGAN ALMARHUM/AH DAN TANGGAL/TEMPAT KEMATIAN

301 Siapakah nama Almarhum/ah? ................................................................................................


305

................................................................................................

JAM

MENIT

UMUR DALAM TAHUN

TAMAT PT __________________________________________

202 Nama Responden

KATEGORI KODE LANJUT KE


TAMAT SLTP ______________________________________

TAMAT SLTA __________________________________________

Umur Responden

Jenis Kelamin Responden LAKI-LAKI _________________________________________

PEREMPUAN ___________________________________

TIDAK SEKOLAH _____________________________________

TIDAK TAMAT SD _____________________________________

TAMAT SD ___________________________________________

1

NO. PERTANYAAN

201 Catatan waktu awal wawancara

2

1

2

203

204

(sebutkan)

96

01

02

03

04

05

06

07

206 Apakah hubungan Bapak/Ibu/Sdr/i dengan

3

4

5

6

AYAH ______________________________________________

2

4

TIDAK _______________________________________________

ANAK _______________________________________5

207

205 Apakah pendidikan terakhir Bapak/Ibu/Sdr/i?

SEKOLAH _______________________________________

TNI/POLRI ___________________________________________

PNS ______________________________________________

WIRASWASTA/DAGANG _____________________________

PETANI ____________________________________________

NELAYAN _________________________________________

BURUH _________________________________________

KATEGORI KODE LANJUT KENO. PERTANYAAN

Apakah pendidikan tertinggi Almarhum/ah?

→ JIKA TANGGAL DAN BULAN TIDAK DIKETAHUI


Apakah Almarhum/ah menderita darah tinggi?

TIDAK TAMAT SD ____________________________________

BELUM MENIKAH ____________________________________

MENIKAH ________________________________________


FASILITAS KESEHATAN LAINNYA _______________________

RUMAH ___________________________________________

TAHUN

LAINNYA ..........................................................................

TIDAK TAHU ______________________________________

TAMAT SD _______________________________________

TAMAT SMP _______________________________________

TAMAT SMA ______________________________________

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

3

HIDUP BERPISAH _________________________________

TIDAK TAHU ______________________________________

TAMAT DIPLOMA ___________________________________

TAMAT PT _________________________________________

TIDAK TAHU _________________________________________

KODE 98

CERAI HIDUP _____________________________________

BULAN

2

RUMAH SAKIT ___________________________________

308 Kapan Almarhum/ah meninggal?

4

1

TANGGAL

306

CERAI MATI _____________________________________

TIDAK SEKOLAH _______________________________________

YA ______________________________________________

5

2

Almarhum/ah meninggal? ..................................................................................................................................

.......................................................................................................................................................................................................

402 Penyebab kematian berdasarkan responden : ...............................................................................................................

.......................................................................................................................................................................................................

307 Status perkawinan Almarhum/ah? 1

8

309 Di manakah Almarhum/ah meninggal? 1






8

502 1

2TIDAK ___________________________________________

TIDAK TAHU ______________________________________8

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

501 1

5. RIWAYAT PENYAKIT/MEDIS ALMARHUM/AH SEBELUMNYA

6

8


401 Dapatkah Bapak/Ibu/Sdr menceritakan tentang riwayat penyakit/kejadian yang menyebabkan

.......................................................................................................................................................................................................

diabetes?

Apakah Almarhum/ah menderita kencing manis/

(sebutkan)

2

3

8

3

4

5

6

7

2


Apakah Almarhum/ah menderita kanker?

Apakah Almarhum/ah menderita epilepsi/ayan?

2

2

504 1

2

8

503 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

Apakah Almarhum/ah menderita asma?

505 1

2

8

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

507

2

8

506 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

Sebutkan jenis dan lokasi kanker? JENIS ............................................................................

Apakah Almarhum/ah menderita malnutrisi/

kurang gizi?

2

8

508 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

Apakah Almarhum/ah menderita tuberkulosis?

Apakah Almarhum/ah menderita HIV/AIDS?

LOKASI ............................................................................

8

508

508

510 1

2

8

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

Apakah Almarhum/ah pernah menderita

atau didiagnosis penyakit lain?

509 1

601

6. RIWAYAT CEDERA

601 1

511

............................................................................

NAMA PENYAKIT ............................................................................

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

Sebutkan jenis diagnosis penyakit lainnya yang

diderita Almarhum/ah?

Apakah Almarhum/ah mengalami cedera yang

menyebabkan kematian?

8 601

604

604

602 01

02

Apakah jenis cedera yang menyebabkan

(sebutkan)

2

Almarhum/ah meninggal?

KECELAKAAN LALU LINTAS __________________________

JATUH ___________________________________________

603 1

2

96

98

05

06

03

04

YA ______________________________________________

TIDAK ___________________________________________



(sebutkan)

TENGGELAM _____________________________________

KERACUNAN ............................................................................

KEBAKARAN _____________________________________

KEKERASAN ________________________________________

LAINNYA ............................................................................

TIDAK TAHU ____________________________________

8

604 Apakah menurut anda Almarhum/ah

8TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

bunuh diri?

1

2

8


701

8

1

2

1

Berapa lama (hari/bulan) Almarhumah mengalami

YA ______________________________________________

1

2

melalui vagina di luar masa menstruasi/haid?

BULAN ________________________________

MINGGU ____________________________

TIDAK TAHU ______________________________

1

2

9

MINGGU ____________________________

8

ulkus/luka atau pembengkakan?

BULAN ________________________________

keputihan atau keluar cairan tidak normal dari vagina?

YA ______________________________________________

8

Sebutkan jenis binatang/serangga tersebut! ANJING __________________________________________

ULAR ____________________________________________

SERANGGA ______________________________________

TIDAK TAHU ____________________________________

LAINNYA ............................................................................

(sebutkan)

3

6

605 1

2

Apakah Almarhum/ah digigit binatang/serangga YA ______________________________________________

TIDAK ___________________________________________sehingga meninggal? A

606 1

2

8TIDAK TAHU ______________________________________

7. GEJALA DAN TANDA YANG DITEMUKAN PADA PERIODE TERAKHIR UNTUK PEREMPUAN (ALMARHUMAH)

701 Apakah pada payudara Almarhumah terdapat 1

8

2

ulkus/luka atau pembengkakan pada payudaranya?

702

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

BULAN ________________________________

MINGGU ____________________________

2

705

TIDAK TAHU ______________________________

TIDAK TAHU ______________________________________

Apakah Almarhumah mengalami perdarahan 1

704

banyak perdarahan selama menstruasi/haid?

Berapa lama (hari/bulan) Almarhumah mengalami

TIDAK TAHU ______________________________

BULAN ________________________________

MINGGU ____________________________

TIDAK TAHU ______________________________

perdarahan selama menstruasi/haid?

9

YA ______________________________________________

2

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

9

8

707 Apakah dari vagina Almarhumah keluar cairan 1

yang tidak normal (keputihan)? 2

banyak perdarahan selama menstruasi/haid?

706 Berapa lama (hari/bulan) Almarhumah mengalami

8

2

9 8

9 8

TIDAK ___________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

8. GEJALA DAN TANDA YANG BERHUBUNGAN DENGAN KEHAMILAN

801 Apakah Almarhumah sedang hamil atau melahirkan, 1

A

JIKA "PEREMPUAN"

PERIKSA JAWABAN DARI PERTANYAAN 302 UNTUK JENIS KELAMIN ALMARHUM/AH : JIKA "LAKI-LAKI"

8

89

atau nifas ketika meninggal?2

703 Apakah Almarhumah mengalami banyak 1

901

708 Berapa lama (hari/bulan) Almarhumah mengalami

9

9

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

703

703

705

705

707

707

801

801

818

818

A


______

termasuk kehamilan terakhir?

1 2

9 8

PERDARAHAN DARI VAGINA

2

1 2

2 8

Berapa kali Almarhumah mengalami kehamilan,

Y

Perdarahan dari Vagina?

BULAN ________________________________

MINGGU ____________________________

TIDAK TAHU ______________________________

KEHAMILAN ________________________________

TIDAK TAHU ___________________________

8

1

tersebut dibawah ini :

2

Kejang?

Demam Tinggi?

1 2

T

2 8

apakah Almarhumah mengalami hal-hal

Selama 3 bulan terakhir kehamilannya,804

Sakit Perut Hebat (Bukan sakit persalinan)?

1 2 8

805 Apakah Almarhumah meninggal ketika 1

8

9.

8. 1 2

4. 1

8

YA ______________________________________________

8

5.

7.

6. 1

10.

Pucat dan Nafas Cepat?

Penyakit Lain?

6.

7.

8.

9.

10.

8

806 1

< 42 hari setelah melahirkan? 2

sedang bersalin, tetapi anak belum lahir? 2

8

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

meninggal?

807 Berapa hari setelah melahirkan Almarhumah JAM ________________________________1

HARI ____________________________ 2

TIDAK TAHU ______________________________9

Apakah Almarhumah meninggal saat bersalin atau

818

818

808 Apakah Almarhumah mengalami perdarahan 1

8

YA ______________________________________________


hebat pada saat awal timbulnya tanda-tanda 2

persalinan (kala 1)? 8

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________


hebat selama proses persalinan sebelum bayi

9 8

lahir? 8

812 Apakah Almarhumah mengalami proses 1

persalinan yang lama (>24 jam)? 2

8

811 Apakah Almarhumah mengalami kesulitan 1

ketika melahirkan placenta? 2

8

YA ______________________________________________

TIDAK ___________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

hebat setelah bayi lahir? 2

8TIDAK TAHU ______________________________________

3. 1

2.

1.

1802 Jika ya, berapa usia kehamilan terakhir?

1 2

8

TT

803

9 9 8

Keluar Cairan Vagina Bau?

2

8

DEMAM TINGGI

SAKIT PERUT HEBAT

PUCAT DAN NAFAS CEPAT

PENYAKIT LAIN

(sebutkan) ............................................................................

1.

2.

3.

4.

5.

KELUAR CAIRAN VAGINA BAU

WAJAH BENGKAK

SAKIT KEPALA

PANDANGAN KABUR

KEJANG

Wajah Bengkak?

Sakit Kepala?

Pandangan Kabur?

2


dalam waktu dekat sebelum meninggal?

POLINDES _____________________________________

PRAKTEK BIDAN ___________________________________

RUMAH _________________________________________

LAINNYA ..........................................................................

(sebutkan)

98

814 Bagaimana cara proses persalinannya? 1

2

2

8

813 1Apakah Almarhumah melahirkan secara normal?

FORCEP _____________________________________

VAKUM _________________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

815 Apakah Almarhumah mengeluarkan cairan 1

vagina yang berbau? 2

8

3

6

YA ______________________________________________

TIDAK ___________________________________________

OPERASI SEKSIO/SESAR _______________________________

LAINNYA ..........................................................................

TIDAK TAHU ______________________________________

(sebutkan)

816 Dimana Almarhumah melahirkan? 01

02

03

TIDAK TAHU ______________________________________

RUMAH SAKIT ____________________________________

PUSKESMAS ______________________________________

RUMAH BERSALIN __________________________________

817 Siapakah yang menolong persalinan?

96

98

01

02

03

05

06

04

TIDAK TAHU ______________________________________

DOKTER _____________________________________

BIDAN ________________________________________

PERAWAT ____________________________________

8

818 Apakah Almarhumah mengalami keguguran

96

1

04

05

06

YA ______________________________________________

TIDAK ___________________________________________

keguguran? 2

8

8

819 Apakah Almarhumah meninggal saat mengalami 1

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

LAINNYA ..........................................................................

(sebutkan)

TIDAK TAHU ______________________________________

2

DUKUN BERSALIN _______________________________

KELUARGA ______________________________________

IBU SENDIRI _____________________________________

821 Berapa bulan umur kehamilannya saat

9 8

820 Berapa hari sebelum meninggal Almarhumah

perdarahan hebat setelah keguguran? 2

8

9 8

822 Apakah Almarhumah mengalami 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

TIDAK TAHU ____________________________Almarhumah mengalami keguguran?

mengalami keguguran?

HARI ______________________________________

TIDAK TAHU ______________________________

BULAN _______________________________

dengan sendirinya secara spontan? 2

8

823 Apakah keguguran tersebut terjadi 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

(KEGUGURAN : HAMIL < 22 MINGGU) 901

821

821

901

901

901

815

815


TIDAK ___________________________________________

2

1

TIDAK TAHU ______________________________

YA ______________________________________________

TIDAK TAHU ______________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

2

MINGGU ________________________________

BULAN ____________________________

8TIDAK TAHU ______________________________________

YA ______________________________________________

909 Apakah batuknya parah? 1

Apakah demamnya terus menerus atau 1

824 Apakah Almarhumah menggunakan obat atau 1YA ______________________________________________

menderita sakit sebelum meninggal?

9. GEJALA DAN TANDA YANG DITEMUKAN PADA PERIODE TERAKHIR SAKITNYA ALMARHUM/AH

901 Berapa lama (minggu/bulan) Almarhum/ah

melakukan tindakan untuk menginduksi / 2

memicu terjadinya keguguran? 8

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

8

8

902 Apakah Almarhum/ah mengalami 1

demam?2

904

9 89

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

hilang timbul?2

TIDAK TAHU ______________________________

demam?

HARI ________________________________1

BULAN ____________________________ 2

TIDAK TAHU ______________________________9

batuk?

908 Berapa lama (hari/bulan) Almarhum/ah mengalami

menggigil? 2

903 Berapa lama (hari) Almarhum/ah mengalami

9 8

TERUS-MENERUS ___________________________

HILANG TIMBUL ____________________________________

TIDAK TAHU ________________________________________


Apakah Almarhum/ah mengalami demam hanya

pada malam hari?

8

905 1

2

YA ______________________________________________

BULAN ____________________________

1

TIDAK ___________________________________________

910 Apakah batuknya berdahak (produktif)? 1

2

8

2

8

907 Apakah Almarhum/ah mengalami batuk? 1

2

8TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

912 Apakah Almarhum/ah mengalami keringat 1

malam tanpa melakukan aktifitas sebelumnya? 2

8

911 Apakah ketika batuk keluar darah? 1

(batuk berdarah) 2

8

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

9 89

HARI ________________________________

907

907

913

913


1

2

TIDAK TAHU ______________________________

1

2

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

TIDAK ___________________________________________

harus diganjal oleh beberapa bantal?

2

terasa di ulu hati dibawah tulang tengah dada? 2

TERUS MENERUS ___________________________________

HILANG TIMBUL _________________________________

8


TIDAK TAHU ______________________________________

HARI ________________________________

BULAN ____________________________

TIBA-TIBA _________________________________________

PERLAHAN-LAHAN _______________________________

TIDAK TAHU ______________________________

8

nyeri dada?

8

920 Apakah nyeri dada timbul secara tiba-tiba atau 1

perlahan-lahan?2

923 1

2terasa dibagian jantung dan menyebar ke lengan

8

924 Apakah nyeri dada yang dialami Almarhum/ah 1

terasa dibagian tulang iga?

melakukan aktivitas rutin sehari-hari disebabkan

8

913 Apakah Almarhum/ah pernah mengalami sulit 1

bernafas? 2

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

915 Apakah Almarhum/ah pernah tidak dapat 1

2

sulit bernafas?


9 89

HARI ________________________________

BULAN ____________________________

YA ______________________________________________

TIDAK ___________________________________________

916 Apakah Almarhum/ah sulit bernafas jika dalam 1

keadaan berbaring pada posisi datar sehingga 2

mengalami sulit bernafas? 8

918 Apakah Almarhum/ah pernah mengalami nyeri 1

dada? 2

8

917 Apakah Almarhum/ah ketika bernafas 1

mengeluarkan bunyi mengi? 2

* TIRUKAN SUARANYA

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

9 89

TIDAK TAHU ____________________________________

2


berlangsung?3

921 Ketika Almarhum/ah mengalami nyeri dada 1

terparah, berapa lama kejadian tersebut2

< SETENGAH JAM ________________________________

SETENGAH JAM - 24 JAM __________________________

LEBIH DARI 24 JAM _____________________________

TIDAK TAHU ___________________________________

YA ______________________________________________

8TIDAK TAHU ____________________________________

terasa terus menerus atau hilang timbul?

8

Apakah nyeri dada yang dialami Almarhum/ah

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________kiri? 8

8


918

918

928

928


PERIKSA JAWABAN DARI PERTANYAAN 801, 805, 819 UNTUK MELIHAT APAKAH

2

JIKA "TIDAK"

diare?

muntah?

BULAN ____________________________ 2

2

9 89TIDAK TAHU ______________________________

8

8

8

JIKA "PEREMPUAN"

C

Apakah Almarhum/ah pernah mengalami diare? 1

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

927 Apakah Almarhum/ah mengalami jantung 1

berdebar-debar? 2

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

928


8TIDAK TAHU ______________________________________

HARI ________________________________1

8

926 Apakah nyeri dada dirasakan semakin 1

parah ketika Almarhum/ah batuk?

930 Apakah diare yang dialami Almarhum/ah 1

terus menerus atau hilang timbul? 2

9 89

TERUS MENERUS ___________________________________

HILANG TIMBUL _________________________________

TIDAK TAHU ____________________________________

TIDAK TAHU ______________________________

8

2

932 Ketika diare paling parah, berapa kali buang air JUMLAH

dalam tinja almarhum/ah? 8

931 Selama menderita penyakit terakhir (sebelum 1

meninggal), apakah pernah terdapat darah di 2

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

933 Apakah Almarhum/ah pernah mengalami 1

besar dalam sehari? TIDAK TAHU

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

muntah?

934 Berapa lama (hari/bulan) Almarhum/ah mengalami HARI ________________________________1

BULAN ____________________________ 2

B

B8

9

936 Ketika muntah paling parah, berapa kali muntah

(seperti darah) atau lainnya? 3

935 Apakah muntahnya berwarna kehitaman 1

seperti kopi atau berwarna merah segar 2

SEPERTI WARNA KOPI _____________________________

WARNA MERAH TERANG/DARAH _____________________

LAINNYA ………………………………………………………………………..

TIDAK TAHU _______________________________________

JUMLAH _______________________________

(SEBUTKAN)

C

dalam sehari?9 8

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

2

8

JIKA "YA"

937

ALMARHUM/AH MENINGGAL SAAT HAMIL, MELAHIRKAN, KEGUGURAN ATAU NIFAS :

B PERIKSA JAWABAN DARI PERTANYAAN 302 UNTUK JENIS KELAMIN ALMARHUM/AH : JIKA "LAKI-LAKI"

937 Apakah Almarhum/ah mengalami nyeri perut? 1

TIDAK TAHU ________________________________

933

933

937

946

939

939


HARI ________________________________1

nyeri perut?


BULAN ____________________________ 2

8

939 Apakah perut Almarhum/ah terlihat/ teraba 1

kembung/bengkak dan kencang? 2

9 89

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

TIDAK TAHU ______________________________

943

terlihat/teraba menggembung dan kencang?

940 Berapa lama (hari/bulan) perut Almarhum/ah

9 89

HARI ________________________________1

BULAN ____________________________ 2

TIDAK TAHU ______________________________


tidak BAB selama satu hari atau lebih? 2

bulan? TIDAK TAHU ________________________________ 8

941 Apakah proses terjadinya penggembungan perut 1

tersebut terjadi dalam hitungan hari atau hitungan BERTAHAP DALAM HITUNGAN BULAN ___________2

CEPAT DALAM HITUNGAN HARI

YA ______________________________________________

TIDAK ___________________________________________

8

943 Apakah ada benjolan di perut Almarhum/ah? 1

2

8TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

946

946

945 Di perut bagian mana terdapat benjolan 1

tersebut? 2

perut Almarhum/ah?

944 Berapa lama (hari/bulan) ada benjolan di

9 89

HARI ________________________________1

BULAN ____________________________ 2

TIDAK TAHU ______________________________

PERUT KANAN ATAS __________________________________

PERUT KIRI ATAS __________________________________

3

YA ______________________________________________

TIDAK ___________________________________________

kesulitan/kesukaran menelan makanan padat?


8TIDAK TAHU ______________________________________

HARI ________________________________1

BULAN ____________________________ 2

PEERUT BAGIAN BAWAH __________________________

SELURUH PERUT __________________________________

TIDAK TAHU _______________________________________

948

948

4

8

950

948 Apakah Almarhum/ah merasa kesulitan 1

atau kesakitan ketika menelan makanan cair? 2

9 89

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

950 Apakah Almarhum/ah mengalami sakit kepala? 1

946 Apakah Almarhum/ah merasa kesulitan 1

atau kesakitan ketika menelan makanan padat? 2

TIDAK TAHU ______________________________

HARI ________________________________1

BULAN ____________________________ 2

TIDAK TAHU ______________________________

kesulitan/kesukaran menelan makanan cair?

8

8TIDAK TAHU ______________________________________

2

950


9 89

YA ______________________________________________

TIDAK ___________________________________________ 953

953

943


BULAN ____________________________ 2

YA ______________________________________________

TIBA-TIBA _________________________________________

CEPAT DALAM SEHARI ____________________________

PERLAHAN BEBERAPA HARI _______________________

TIDAK TAHU ___________________________________

sakit kepala?


BULAN ____________________________ 2

8

952 Apakah sakit kepalanya berat? 1

2

9 89

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

TIDAK TAHU ______________________________


kaku kuduk pada leher?

8

953 Apakah Almarhum/ah mengalami kaku 1

kuduk pada leher? 2

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

HARI ________________________________1

BULAN ____________________________ 2

955

955

8


gangguan mental? 2

9 89

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

gangguan mental?


TIDAK TAHU ______________________________

HARI ________________________________1

BULAN ____________________________ 2

958

958

penurunan kesadaran atau tidak memberikan reaksi?


kesadaran atau tidak memberikan reaksi? 2

8

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

9 89

8

958 Apakah Almarhum/ah mengalami penurunan 1

perlahan dalam beberapa hari? 3

957 Apakah gangguan mental yang dialami timbul 1

secara tiba-tiba atau cepat dalam sehari atau 2

1

BULAN ____________________________ 2


960 Apakah proses penurunan kesadaran terjadi 1

secara tiba-tiba, cepat dalam sehari atau 2

9 89

kejang? 2

8

8

961 Apakah Almarhum/ah mengalami 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

TIBA-TIBA _________________________________________



TIDAK TAHU ___________________________________

TIDAK TAHU ______________________________

963 Apakah Almarhum/ah pernah mengalami tidak 1

dapat membuka mulut (trismus)? 2

kejang?


9 89

YA ______________________________________________

TIDAK ___________________________________________

1HARI ________________________________

TIDAK TAHU ______________________________

8TIDAK TAHU ______________________________________

TIDAK TAHU ______________________________

HARI ________________________________

961

961

963

963

965

965


89TIDAK TAHU ______________________________

8

tidak dapat membuka mulut?


8

965 Apakah Almarhum/ah mengalami kaku pada 1

seluruh tubuhnya? 2

9 89

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

BULAN ____________________________ 2

TIDAK TAHU ______________________________

967 Apakah Almarhum/ah mengalami kelumpuhan 1

pada salah satu sisi tubuhnya? 2

kaku pada seluruh tubuhnya?


9 89

YA ______________________________________________

TIDAK ___________________________________________

HARI ________________________________1

BULAN ____________________________ 2

TIDAK TAHU ______________________________

kelumpuhan pada salah satu sisi tubuhnya?


8TIDAK TAHU ______________________________________


969 Apakah kelumpuhan tersebut timbul 1


9 89TIDAK TAHU ______________________________



TIBA-TIBA _________________________________________

BULAN ____________________________ 2

pada tungkai kakinya? 2

8

8

970 Apakah Almarhum/ah mengalami kelumpuhan 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

TIDAK TAHU ___________________________________

kelumpuhan pada tungkai kaki?


BULAN ____________________________ 2

973

973

973 Apakah ada perubahan warna air seni pada 1


972 Apakah kelumpuhan tersebut timbul 1


YA ______________________________________________

TIBA-TIBA _________________________________________



TIDAK TAHU ___________________________________

perubahan warna pada air seni?


Almarhum/ah? 2

8

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

HARI ________________________________1

BULAN ____________________________ 2

975

975

8

975 Selama sakit terakhirnya apakah pada Almarhum/ah 1

pernah terlihat ada darah dalam air seninya? 2

9 89

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

TIDAK TAHU ______________________________

977

977

ada darah pada air seni?


9 89

HARI ________________________________1

BULAN ____________________________ 2

TIDAK TAHU ______________________________

HARI ________________________________1

9

HARI ________________________________1

967

967

970

970


TIDAK TAHU ______________________________

TERLALU BANYAK _________________________________

TERLALU SEDIKIT _________________________________

TIDAK ADA SAMA SEKALI ________________________

TIDAK TAHU ___________________________________

RUAM CAMPAK _________________________________________

RUAM BERISI CAIRAN BENING _____________________

HARI ________________________________

8

(sebutkan) ..........................................................................

BULAN ____________________________ 2

977 Apakah ada perubahan jumlah air seni yang 1

dikeluarkan Almarhum/ah dalam sehari? 2

YA ______________________________________________

TIDAK ___________________________________________

perubahan dalam jumlah air seni yang dikeluarkan


8TIDAK TAHU ______________________________________

3

979 Berapa banyak jumlah air seni yang dikeluarkan 1

Almarhum/ah dalam sehari? 2

9 89

HARI ________________________________1

BULAN ____________________________ 2

TIDAK TAHU ______________________________

apakah Alamarhum/ah menderita bintik-bintik 2

merah (ruam) di kulit? 8

8

980 Selama sakit yang menyebabkan kematiannya, 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

982 Dimana lokasi bintik-bintik merah tersebut? Y T TT

bintik-bintik merah (ruam) di kulit?9 8

981 Berapa lama (hari) Almarhum/ah mengalami HARI ____________________________________

TIDAK TAHU ______________________________

4 Bagian tubuh lainnya 1 2 8

3 Tangan dan kaki? 1 2

8

2 Badan? 1 2 8

1 Muka? 1 21. MUKA

2. BADAN

3. TANGAN DAN KAKI

3. TEMPAT LAINNYA

983 Seperti apa bentuk bintik-bintik merah (ruam) 1

RUAM BERISI PUS (NANAH) ________________________

2

8

8

984 Apakah Almarhum/ah mengalami mata merah? 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

TIDAK TAHU ___________________________________

8

985 Apakah ada perdarahan keluar dari hidung, 1

mulut atau anus? 2

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

tersebut? 2

3

8


penurunan berat badan? 2

8TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________


herpes zoster/cacar monyet/lilitan? 2

penurunan berat badan?

987,1 Berapa lama (hari/bulan) Almarhum/ah mengalami

9 89

8

987,2 Apakah Almarhum/ah terlihat sangat kurus? 1

2

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

1

980

980

984

984

988

988


HARI ________________________________1

HARI ________________________________1

BULAN ____________________________

8

1 2 8

1 2 8

T TT

988 Apakah ada luka/bercak putih di lidah atau 1

mulut Almarhum/ah? 2

YA ______________________________________________

TIDAK ___________________________________________

luka/bercak putih pada lidah atau mulut?


8TIDAK TAHU ______________________________________

BULAN ____________________________ 2

8

989 Apakah terjadi pembengkakan pada bagian tubuh 1

Almarhum/ah? 2

9 89

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

TIDAK TAHU ______________________________

989,2 Dimana lokasi pembengkakan tersebut?

pembengkakan tersebut?

989,1 Berapa lama Almarhum/ah mengalami

9 89

HARI ________________________________1

BULAN ____________________________ 2

TIDAK TAHU ______________________________

Y T TT

4 Seluruh tubuh?

3 Pergelangan kaki?

2 Sendi?

1 Muka?

getah bening (kelenjar leher, ketiak, sela paha) 2

Almarhum/ah? 8

1 2 8

1 2 8

1. MUKA

2. SENDI

3. PERGELANGAN KAKI

4. SELURUH TUBUH

5. TEMPAT LAIN

1 2

990 Apakah ada benjolan kelenjar getah bening 1

5 Tempat lain?

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

1 2 8

990,2 Dimana lokasi benjolan kelenjar getah bening tersebut?

benjolan kelenjar getah bening tersebut?


9 89

HARI ________________________________1

BULAN ____________________________ 2

(sebutkan) ..........................................................................

Y

4 Tempat Lain?

3 Selangkangan?

2 Ketiak?

1 Leher?

berubah menjadi kuning? 2

8

991 Apakah bagian putih mata Almarhum/ah 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

1 2 8

1 2

(sebutkan) ..........................................................................

1. LEHER

2. KETIAK

3. SELANGKANGAN

992 Apakah Almarhum/ah kelihatan pucat (lemah/ 1

kurang darah) atau terlihat pucat pada telapak 2

Almarhum/ah menjadi kuning?

991,1 Berapa lama (hari/bulan) bagian putih mata

9 89

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________

2

terlihat pucat?

992,1 Berapa lama (hari/bulan) Almarhum/ah

tangan, mata atau bantalan kukunya? 8TIDAK TAHU ______________________________________

9 89

HARI ________________________________1

BULAN ____________________________

TIDAK TAHU ______________________________

8

1 2 8

2

TIDAK TAHU ______________________________

4. TEMPAT LAIN

989

989

990

990

991

991

992

992

993

993


Y T TT

8

Y

3. Puskesmas? 8

1 2 8

Klinik Swasta? 1 2 86. RS Swasta? 1 2

1 24. RS Pemerintah? 15. 6. RS SWASTA

T

2

7. APOTIK, TOKO OBAT, WARUNG 8

2

TT

1 2 8

2

8

1

pemberian cairan melalui infus?

1 Rehidrasi oral (minum oralit) dan atau

1

penyebab kematiannya? 2

4. PENGOBATAN LAINNYA

8

993 Apakah terdapat borok atau bisul besar atau 1

luka pada tubuh Almarhum/ah? 2

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

993,2 Dimanakah letak luka/bisul/borok tersebut?


borok atau bisul besar atau luka pada tubuhnya?


9 89

(sebutkan) ............................................................................

...................................................................................................................

HARI ________________________________1

BULAN ____________________________ 2

TIDAK TAHU ______________________________

yang menyebabkannya meninggal?

SALIN RESEP/CATATAN KUITANSI JIKA ADA

1002 Sebutkan jenis obat (pengobatan) apa saja yang

diberikan kepada Almarhum/ah untuk penyakit

8

1001 Apakah Almarhum/ah mendapat pengobatan 1

untuk penyakit terakhirnya sebelum meninggal? 2

...................................................................................................................

...................................................................................................................

...................................................................................................................

...................................................................................................................

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

8. Tempat Lain?1 8

9 8

JUMLAH PERIKSA

TIDAK TAHU

YA ______________________________________________

TIDAK ___________________________________________

(sebutkan) ..........................................................................

8. TEMPAT LAINNYA7. Apotik, Toko Obat, Warung?

1003 Jenis pengobatan apa saja yang diterima?

1004

yang dipasang melalui hidung (NGT)?

4 Jenis pengobatan lainnya?

Dimana saja Almarhum/ah mendapat pengobatan

3 Pemberian makanan/obat dengan selang

2 Transfusi darah?

2. Pengobatan Tradisional?

1. Rumah?

untuk sakit yang menyebabkannya meninggal?

1006 Apakah petugas kesehatan menjelaskan penyakit/

1007 Apa yang dijelaskan oleh petugas kesehatan

tentang penyakit/penyebab kematiannya?

8

............................................................................

……………………………………………………………………………………

............................................................................

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

pernah mendapatkan pelayanan oleh petugas

kesehatan?

1005 Sebelum meninggal, berapa kali Almarhum/ah

8TIDAK TAHU ______________________________________

1008 Apakah Almarhum/ah menjalani operasi 1

untuk pengobatan penyakitnya? 2

(sebutkan) ..........................................................................

1. RUMAH

2. PENGOBATAN TRADISIONAL

3. PUSKESMAS

4. RS PEMERINTAH

5. KLINIK SWASTA

1 2 8

1 2 8

1 2 8

1. ORALIT/INFUS CAIRAN

2. TRANSFUSI DARAH

3. NGT

1 2 8

1008

1008

1008

1008

1101

1101

1001

1001


8

SETIAP HARI ___________________________________

SEMINGGU SEKALI ___________________________________

KADANG-KADANG ____________________________________

TIDAK TAHU _________________________________________

operasi tersebut dilakukan?

8

TIDAK TAHU ___________________ 9 8

1009 Berapa lama (hari) sebelum meninggal HARI __________________________

8TULIS "00" JIKA KURANG DARI SATU TAHUN

1102 Berapa lama (tahun) Almarhum/ah sudah melakukan TAHUN

8

3

6

1010 Bagian tubuh mana yang dioperasi? 1

2

PERUT _________________________________________

LAINNYA ............................................................................

TIDAK TAHU

KEPALA _______________________________________

peminum alkohol? 2

DADA _________________________________________

(sebutkan)

TULIS "00" JIKA KURANG DARI SATU BULAN

1105 Berapa lama (bulan) sebelum meninggal Almarhum/ah BULAN

YA ______________________________________________

TIDAK ___________________________________________

11. FAKTOR RESIKO

1101 Apakah Almarhum/ah semasa hidupnya seorang 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

3

1103 Seberapa sering Almarhum/ah minum alkohol? 1

2

kebiasaan minum alkohol?TIDAK TAHU 9

8TIDAK TAHU ______________________________________

minum alkohol? 2

8

TIDAK TAHU 9

1104 Apakah Almarhum/ah sudah berhenti 1YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

1106 Apakah Almarhum/ah pernah merokok selama 1

hidupnya? 2

berhenti minum alkohol?TIDAK TAHU 9 8

1108 Seberapa sering Almarhum/ah merokok? 1

2

SETIAP HARI ___________________________________

SEMINGGU SEKALI ___________________________________

KADANG-KADANG ____________________________________

TIDAK TAHU _________________________________________8

8TULIS "00" JIKA KURANG DARI SATU TAHUN

1107 Sudah berapa lama (tahun) Almarhum/ah merokok? TAHUN

8

1110 Apakah Almarhum/ah sudah berhenti merokok? 1

2

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

1109 Berapa batang rokok yang dikonsumsi BATANG ROKOK

3

1111 Berapa lama (bulan) sebelum meninggal BULAN

Almarhum/ah berhenti merokok?TIDAK TAHU 9 8

TULIS "00" JIKA KURANG DARI SATU BULAN

Almarhum/ah dalam sehari?TIDAK TAHU ___________________ 9 8

1106

1106

1106

1106

1201

1201

1201

1201

1201

1201

1201


YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

YA ______________________________________________

TIDAK ___________________________________________

TIDAK TAHU ______________________________________

2

dan Catatan Sipil?

8

8

1

1204 (Bolehkan saya melihat akte kematian tersebut?)TANGGAL BULAN TAHUN



1202 (Bolehkan saya melihat surat keterangan kematian tersebut?)

1203 Apakah Almarhum/ah memiliki Akte Kematian

yang dikeluarkan oleh Kantor Dinas Kependudukan

Surat Keterangan Kematian? 2



1201 Apakah Almarhum/ah mempunyai 1

TANGGAL BULAN TAHUNSALIN TANGGAL, BULAN, DAN TAHUN KEMATIAN

DUA) DAN CATAT TANGGAL KETERANGAN MEDIS TERSEBUT (CATAT INFORMASI MENGENAI ALMARHUM/AH)

MENIT


1301 Apakah ada keterangan kesehatan pendukung 1

lainnya? 2

1302 SALINLAH SEMUA KETERANGAN MEDIS YANG MENDUKUNG DARI DUA PELAYANAN KESEHATAN TERAKHIR (JIKA LEBIH DARI

HASIL VISUM TERSEBUT)

..........................................................................................................................................................................................................................................

1203

..................................................................................................................................................................................................................................................................

..................................................................................................................................................................................................................................................................

YA _______________________________________________

TIDAK ___________________________________________

..........................................................................................................................................................................................................................................

..........................................................................................................................................................................................................................................

1303 SURAT IZIN PENGUBURAN (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM SURAT TERSEBUT)

..........................................................................................................................................................................................................................................

1304 HASIL PEMERIKSAAN VISUM/AUTOPSY FORENSIK (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM

CATATAN PEWAWANCARA


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1305 CATATAN WAKTU AKHIR WAWANCARA JAM

1203

1301

1301

1305

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NAMA DOKTER : ..........................................................................................................................................................................................................................................

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TANDA TANGAN DOKTER : .....................................................................................................


NAMA DOKTER :.....................................................................................................

....................................................................................................................................................................

disebabkan oleh

d.

....................................................................................................................................................................



disebabkan oleh

c.

....................................................................................................................................................................

disebabkan oleh

b.

....................................................................................................................................................................

a.

....................................................................................................................................................................

I. PENYEBAB KEMATIAN MENURUT DOKTER PUSKESMAS SELANG WAKTU MULAI TERJADINYA PENYAKIT SAMPAI MENINGGAL

THN BLN HARI JAM ICD -10



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