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The Lancet, Volume 380, Issue 9858, Pages 1981 - 1982, 8 December 2012
doi:10.1016/S0140-6736(12)62141-2
Indonesia makes maternal health a national priority
Paul C Webster
Analysts have warned that Indonesia will not meet its Millennium Development Goal for maternal health. Can
the country prove them wrong? Paul C Webster reports from Jakarta.
When Indonesian President Susilo Bambang Yudhoyono visited London in late October, the Queen welcomed
him with a 41-gun salute. The pomp matched the circumstances: in meetings with UK Prime Minister David
Cameron and Liberian President Ellen Johnson Sirleaf over the next few days, Yudhoyono's task was to begin
forging a new global development roadmap to replace the Millennium Development Goals (MDGs) when they
expire in 2015. The three leaders are the co-chairs of the UN's High Level post-MDG panel charged with
shaping whatever replaces the eight development goals that countries agreed to in 2000.
Yudhoyono is a vocal international advocate for the MDGs. On his way home to Indonesia from London in early
November, he stopped at an Asian-Europe summit in Laos to stress that full realisation of the MDGs was a
sure way to build a better world. With the 2015 deadline looming, and progress lagging in many nations on
goals such as reducing child and maternal mortality, Yudhoyono is turning up the heat, especially in
Indonesia, where the lifetime risk of maternal death is one in 150 for women, as compared with one in 4000in developed nations.
Nobody hears Yudhoyono's calls more loudly than Indonesia's recently appointed director of maternal health,
Gita Maya Koemara Sakti. It is her job to meet Indonesia's maternal health MDG by reducing mortality to 102
for every 100000 livebirthsone quarter of what they were in 1990. The President has asked us to meet102. He's made it clear it's a national priority, she said in a recent interview at the Indonesian Ministry of
Health headquarters in Jakarta. At the current rate of improvement we will be at 164 in 2015. But we can
do better than that.
Sakti's note of optimism would have seemed wildly unrealistic as recently as 2010, when efforts to reduce
maternal mortality were, by all appearances, moribund. Indonesia, analysts at the UN warned that year, was
not on track to achieve its maternal mortality target. The reasons, according to a World Bank investigation,
were complex. According to many observers, an ambitious national midwifery programme created in the late
1980s that trained and placed 60000 midwives in rural villages and achieved rapid reductions in maternalmortality in the 1990s had faded in the face of apathy, greed, and corruption. Almost a quarter of births were
unassisted by a doctor, nurse, or midwife, and many remote regions of the country reported intractably high
numbers of deaths. Data from verbal autopsies in three districts indicated that high numbers of women were
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Sakti is also overhauling the national midwifery programme. Although this programme is credited with halving
the maternal mortality rate between 1900 and 2000, as the government decentralised health care and
devolved funding to the regions over the past decade, huge numbers of government-trained midwives started
private practices and abandoned the villages. To reinvigorate maternal care in the villages where the largest
number of mothers die, the ministry is offering cash incentives to encourage 72000 traditional birthattendants to work with midwives in the remote villages where they live. The government is also opening
2800 waiting homes where rural women can stay under supervision from midwives near medical clinics.Funding for 9000 health clinics has been increased sixfold over the past 2 years, Sakti says. More than 50% of
maternal deaths occur in villages in the five provinces with the smallest health-care budgets and the most
primitive conditions, Sakti explains. We're getting better data and we know where the deaths are
occurring.
Mien Ratminah, director of programming for the Indonesian Midwives Association, welcomes these reforms.
But she warns that persuading rural women to give birth with trained attendants remains intractably difficult.
Many rural women, she explains, see birthing as a natural process that family members can handle, perhaps
with assistance from traditional village healers who will not refer women to medical facilities in
emergencies.
Ratminah, who served as director of maternal health for the densely populated province of West Java until
2006, also warns that government subsidies for midwives have spawned scores of substandard academies
producing poorly trained midwives amidst numerous corruption charges. Licences for the academies are
issued by the ministry of education, not the ministry of health, Ratminah adds. You can easily buy a licence
and there really is no certification or inspection of the hundreds of new academies.
At the Ministry of Health, Sakti candidly acknowledges Ratminah's concerns. The training for midwives was
transferred from the health ministry to the education ministry and it's difficult to control, she complains.
The academies have mushroomed and there are many questions about their competency. We've established
a special board to tackle this question.
Anne Hyre, director of a $55 million US Government-funded programme developed by the Johns Hopkins
Program for International Education in Gynecology and Obstetrics (Jhpiego) to bolster training in 150
hospitals and 300 community health centres, argues that while the proliferation of inadequately trained
midwives has become a serious impediment to reducing maternal mortality, the lack of emergency obstetrical
care for women is equally serious. The majority of women are dying in facilities where clinical care is poor.
There are not enough obstetricians, gynaecologists, and anaesthetists. And frankly, thanks to the education
fiasco, there may be too many so-called midwives.
Hyre's programme is funding efforts to bolster emergency care in partnership with the Budi Kemuliaan
Hospital and Midwifery Academy in Jakarta, which is Indonesia's oldest maternity hospital. The hospital's
director, Mohammad Baharuddin, is leading efforts to overhaul clinical care in five provinces by instituting
clinical audits examining why women die in these facilities. These audits, he explains almost always identify
the same culprits: a poor referral system to get help for women requiring emergency care, lack of trained
personnel, poor hygiene in hospitals, and squandered financial resources.
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Baharuddin is not optimistic Indonesia will achieve its maternal mortality target, despite the President's
decrees. We've broken the MDG promise, Baharuddin said on a tour of the spotless maternity ward in Budi
Kemuliaan Hospital where scores of midwives tended to women and newborns. We're not on track. In the
rural areas there is inadequate transportation available to get women to clinical facilities, and not enough
trained personnel in the facilities. Even here in Jakarta, there are not enough hospital beds and not enough
financial support for women facing catastrophic health costs.
These are all issues the government is attempting to address, notes Untung Suseno Sutarjo, senior finance
adviser to the Indonesian Ministry of Health. We began imposing standards last year for clinical conditions,
and we are extending basic emergency obstetrical care, he explains. We are also considering paying
transportation costs to get women in rural areas to health services. We know they can't reach the services
because they don't have money. But we also know many women consider delivering their babies outside of
their homes to be bad luck.
Copyright 2012 Elsevier Limited. All rights reserved. The Lancet is a registered trademark of Elsevier Properties S.A., used under licence.The Lancet.com website is operated by Elsevier Inc. The content on this site is intended for health professionals.
Full-size image (20K) Paul C Webster
Mien Ratminah
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