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PROVINCIAL REPRODUCTIVE

HEALTH & MPS PROFILE


OF INDONESIA
(2001-2006)

Departemen Kesehatan RI

World Health Organization

World Health Organization 2008


This document is not a formal publication of the World Health Organization (WHO) and all rights are reserved
by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated,
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The designations employed and the presentation of the material in this publication do not imply the expression
of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any
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The World Health Organization does not warrant that the information contained this publication is complete
and correct and shall not be liable for any damages incurred as a result of its use. The views expressed in this
document by named researchers are solely the responsibility of those researchers.
Printed in Indonesia
World Health Organization
Jakarta Country Office
Bina Mulia 1 Bld, 9th Floor
Jl. H. R. Rasuna Said Kav. 10, Kuningan
Ph. : (62-21) 520-43-49
Fax. : (62-21) 520-11-64

Provincial Reproductive Health &


MPS Profile of Indonesia
Technical Contributors:
Dr. Lukman Hendro Laksmono,
Dr. Lukas C. Hermawan,
Dr. Laura Guarenti
Mrs. Riznawaty Imma Batubara
Consultants:
Ms. Gretchen Antelman, MPH Sc.D
Dr. Fransisca Romana Habsari E.P.
Maps:
Mr. Adnan Saleh
Data Collectors:
Mrs. Rizki Primaswastya
Ms. Hepa Susami
Photos Credit:
Ms. Giulia Besana
Mr. Totok Waluyatmoko
Administrative Support:
Mrs. Siti Subiantari
Ms. Nurhayati Nopy
Mr. Adhi Kawidastra
Design & Layout:
PT. Cakra Satria Bhakti

CONTENTS
Foreword by Director of Maternal Health ..............................................
Remarks by Director General of Community Health Ministry of Health
Republic of Indonesia ......................................................................

West Kalimantan.................................................................................... 131


Central Kalimantan ................................................................................ 137

South Kalimantan .................................................................................. 143


East Kalimantan .................................................................................... 149

Introduction ...........................................................................................

North Sulawesi ...................................................................................... 155


Central Sulawesi.................................................................................... 161
South Sulawesi ...................................................................................... 167

Nanggroe Aceh Darussalam ................................................................

29

Southeast Sulawesi ............................................................................... 173

North Sumatra .......................................................................................

35

Gorontalo ............................................................................................... 179

West Sumatra ........................................................................................

41

West Sulawesi ....................................................................................... 185

Riau .....................................................................................................

47

Jambi .....................................................................................................

53

NTB ...................................................................................................... 191

South Sumatra.......................................................................................

59

NTT ....................................................................................................... 197

Bengkulu................................................................................................

65

Maluku ................................................................................................... 203

Lampung................................................................................................

71

North Maluku ........................................................................................ 209

Bangka Belitung ....................................................................................

77

West Papua ........................................................................................... 215

Kepri Islands ..........................................................................................

83

Papua .................................................................................................... 221

DKI Jakarta............................................................................................

89

Annexes

West Java ..............................................................................................

95

Maps

Central Java .......................................................................................... 101

1. Population density by Province

Yogyakarta............................................................................................. 107

2. First Antenatal Care (ANC) Visit by Province

East Java ............................................................................................... 113

3. Delivery by Skilled Birth Attendants (SBA) by Province

Banten ................................................................................................... 119

4. Postpartum and Neonatal Visit by Province

Bali ...................................................................................................... 125

5. Proportion of Villages with Community Midwives by Province

Provincial Reproductive Health & MPS Profile of Indonesia

6. Proportion of Districts with at Least 4 Puskesmas Trained in Basic


Emergency Obstetric and Neonatal Care (BEONC) by Province
7. Proportion of Districts with Met-Need for Basic Emergency
Obstetric and Neonatal Care (BEONC) by Population by Province
(1 BEONC per 125,000 Population)
8. Proportion of Districts with at Least 1 Comprehensive Emergency
Obstetric and Neonatal Care (CEONC) Hospital by Province
9. Proportion of Districts with Met-Need for Comprehensive
Emergency Obstetric and Neonatal Care (CEONC) by Population
by Province (1 CEONC per 500,000 Population)
10. Proportion of Treated Obstetric Complications by Provice
11. Proportion of Treated Neonatal Complications by Provice
12. Maternal Mortality Ratio by Province
13. Neonatal Mortality Rate by Province
14. Contraceptive Prevalence Rate by Province

D E PA RT E M E N K E S E H ATA N R I

D E PA RT E M E N K E S E H ATA N R I

DIREKTORAT JENDERAL BINA KESEHATAN MASYARAKAT


JL. HR. RASUNA SAID BLOK X5 KAPLING 4-9 JAKARTA 12950
Telp Dirjen 5203871, Set. Ditjen 5221225-5221226

DIREKTORAT JENDERAL BINA KESEHATAN MASYARAKAT


JL. HR. RASUNA SAID BLOK X5 KAPLING 4-9 JAKARTA 12950
Telp Dirjen 5203871, Set. Ditjen 5221225-5221226

Telp.: Dit Bina Kes Ibu 5221229, Dit Bina Kes Anak 5273422, Dit Bina Kes Komunitas 5221228, Dit Bina Gizi Masyarakat 5210176, Dit Bina Kes Kerja 527526

Telp.: Dit Bina Kes Ibu 5221229, Dit Bina Kes Anak 5273422, Dit Bina Kes Komunitas 5221228, Dit Bina Gizi Masyarakat 5210176, Dit Bina Kes Kerja 527526

Foreword
by
Director of Maternal Health

Remarks
by
Director General of Community Health
Ministry of Health
Republic of Indonesia

Let us extend our great blessing to God The Almighty who has helped us in the formulation
of National Reproductive Health Profile 2001 2005, which is expected to be used as one
of the facilities to monitor the updated implementation of reproductive health, relating to the
overall human life cycles starting from pregnancy, birth, childhood, adolescent, adult, up to
elderly. This document is particularly featuring more details on data starting from the periods
of pregnancy, delivery, postpartum, family planning, up to newborn.

The International Consensus of the International Conference on Population and Development


(ICPD) in Cairo 1994 had a new paradigm of reproductive health, which altered the previous
orientation from placing human as an object in population control to be a subject. Indonesia,
being one of the countries that have agreed upon the new paradigm, has undertaken a number
of initiatives to ensure the optimal implementation of reproductive health programmes.

The National Reproductive Health Profile consists of 38 chapters containing maps and tables
complemented with the narration based on the indicators of minimal service standard, health
initiatives, human resources and health status. The data sources were taken from the provincial monthly report and Indonesian Health Demography Survey (SDKI) for Family Planning
and Newborn data. The user of this document is expected to know the description of health
initiatives, resources and status in order to achieve the goal of National Mid-Term Development Plan (RPJMN) 2009 and the MDG 2015.
We would like to convey our sincere appreciation and thank to all stakeholders who have
contributed in the formulation of this document. Our similar appreciation and thank also goes
to WHO for their valuable contribution in the overall process of formulating this document.
The National Reproductive Health Profile contains maps and tables used as a description on
the updated implementation of reproductive health programmes addressed to the policy-makers to make future planning.
Any constructive suggestions and inputs are welcomed in order to improve the document.
Jakarta, December 2007
Director of Maternal Health
Ministry of Health R.I.

Dr Sri Hermiyanti, MSc.

The right and reproductive health aspects are very broad relating to the overall human life
cycles starting from the periods of pregnancy, birth, childhood, adolescent, adult, up to elderly. Aside from the length of age period, reproductive health problems are also exceptionally
complex, starting from pregnancy and delivery-related problems, sexually transmitted and degenerative diseases. The underlying factors are varied; starting from the educational, health,
religious and social-cultural aspects.
The major problem that requires special attention and largely defines the survival of a nation
is the high maternal mortality ratio (MMR). In principal, majority of maternal deaths are avoidable despite the resources limitation. However, to undertake the appropriate initiative, correct
information as the reference for decision-makers is required.
The Reproductive Health Profile contains various maps and tables used to obtain an overview
on the progress of implementation of reproductive health programmes from health initiative,
resources and status.
The user is expected to utilize the gained information to critically evaluate the existing services and programmes as well as carry out necessary follow-ups to promote the reproductive
health programmes.
Our appreciation and thank go to all stakeholders, especially to WHO and GTZ that have
helped in the development and printing of Reproductive Health Profile. It is expected that
the document is beneficial to the effort to accelerate reduction of maternal mortality ratio and
neonatal mortality rate in Indonesia.
Jakarta, November 2007
Director General of Community Health
Ministry of Health R.I.

Dr Sri Astuti S. Soeparmanto, MSc.(PH)


Jakarta, December 2007

INTRODUCTION

INTRODUCTION

he Republic of Indonesia is a nation of over 17,500 islands (6000 inhabited) in South East
Asia, and the worlds largest archipelagic state. With a population of over 220 million, it is
the worlds fourth most populous country and the most populous Muslim-majority nation.
The country shares land borders with Papua New Guinea, East Timor, and Malaysia and
by sea Indonesia neighbors Singapore, The Philippines and Australia. The capital, Jakarta, is on
Java and is the nations largest city, followed by Surabaya, Bandung, Medan, and Semarang.

The population is expected to grow to around 315 million in 2035 based on the current estimated
annual growth rate of 1.25%. Population density varies considerably by region from only 11
people per square kilometer in Maluku/Papua to more than 1000 in Java.
Overall, Indonesias urban population has grown 15% since 2000, and is expected to continue to
expand to 54% by 2010. While the average proportion of people living in urban areas is nearly

Figure 1. Percentage of urban and poor populations, by province (BPS, 2006)


100
90
80
70
60
50
40
30
20
10

% urban

U
KU
AL
U
PA T
PU
IR
JA A
BA
R
M

M
AL

BA
LI
N
TB
N
TT

SU
SU LU
LT T
E
SU NG
LS
SU EL
LT
R
G SU A
L
O
R BA
O
N R
TA
LO

KA
L
KA BA
LT R
EN
KA G
LT
KA IM
LS
EL

D
IY
JA
TI
M

TE
JA N
BA
R
D
JA K I
TE
N
G

BA
N

N
A
SU D
M
SU UT
M
BA
KE R
PR
I
R
IA
U
JA
SU MB
M I
SE
B L
BE AB
E
N
G L
K
LA UL
U
M
PU
N
G

% poor

Provincial Reproductive Health & MPS Profile of Indonesia

INTRODUCTION
established clinics who are able to achieve certain skill and facility standards have worked under
the midwife professional association (IBI), with support from USAID, to form an official private
practice standardization and accreditation program called Bidan Delima. There are over 3000
midwives in this program in selected provinces, with hopes of growing the program further to improve professional and technical standards in midwifery nationwide. Finally, private doctors and
specialists provide antenatal and delivery care services as well.

Figure 2. Percentage of urban and poor, by region (BPS, 2006)


60%

56%

50%

40%

40%

39%

38%

31%

31%
30%
25%
20%
20%

17%

10%

10%

0%

16%

16%

sumatra

java

kalimantan
% urban

sulawesi

bali, nusa tenggara

maluku, papua

% poor

half (48%), this ranges from 18% in East Nusa Tenggara to over 60% in East Kalimantan, Banten,
Yogyakarta, and Jakarta. See Figures 1 and 2 for provincial and regional rates of urban and poor
population, respectively.
Administratively, Indonesia consists of 33 provinces including the capital, Jakarta. Each has its
own political legislature and is headed by a governor. The provinces are subdivided into regencies (kabupaten) and cities (kota), which are further subdivided into sub-districts (kecamatan),
and again into villages (kelurahan or desa). Four provinces have special status: Aceh, Jakarta,
Yogyakarta and Papua. This special status provides greater legislative privileges and a higher
degree of autonomy from the central government in comparison to other provinces.

To further strengthen maternal and child health care services, since the mid-1980s Integrated
Service Posts (posyandu) were established at villages to provide community-based and community-organized programs mainly targeted at addressing nutrition, diarrhea, family planning,
vaccination and general maternal and child health. Fieldworkers and community cadres of the
National Family Planning Coordinating Agency (BKKBN) have played an important role in mobilizing community members by providing health information, and encouraging women and adolescents to come to the posyandu or puskesmas to get basic maternal and family health care, and
family planning services.
Following the implementation of decentralization in 2001, the 440 districts or regencies have become the key administrative units responsible for providing most government services, including
primary health care. Significant budget control and health planning responsibility has been moved
from central level directly to the districts, with limited provincial involvement. The central Ministry
of Health has maintained functions over communicable diseases, setting quality standards, national indicators and targets, overseeing standardized training modules for health professionals,
overseeing pharmaceutical regulation, and advocating with the national government for continued
health financing, and increased access of the poor to public health services.

Local Area Monitoring and Health Data Collection


Organization of the Health System
The Government of Indonesia has employed a tiered approach representing a continuum of care
from provincial and district public hospitals down to the sub-district and village level health facilities. At the sub-district level, primary health centers (puskesmas) are staffed with doctors, nurses,
and midwives, and are equipped to provide primary health care services to an area with about
30,000 population, or about 10 villages. The clinics offer a package of basic services including
maternal and child health, family planning, out-patient care and communicable disease control
(TB DOTS, STIs). They also serve as primary level referral facilities linking patients to district
hospitals. A number of health centers with beds have been established in order to provide service
on site when referral to a district hospital is impractical. The puskesmas are supported by over
20,000 sub-health centers, mobile health centers, and village-based maternity huts.
Health access, particularly for pregnancy and delivery care, has been even more decentralized
with a recent program (1989-1998) under the Ministry of Health which deployed approximately
54,000 village midwives as part of an initiative to ensure greater access to trained delivery providers. These midwives are called bidan di desa (midwife in the village). Currently, there are still
over 30,000 village midwives taking part in the program. In addition, private midwives with more
 Country Health Profile (accessed at: http://www.searo.who.int/LinkFiles/Indonesia_indonesia1.pdf, April 2007)

Local Area Monitoring (SSM) describes the system by which much of the health management
information system data is collected, recorded and reported. Fieldworkers and cadres maintain
detailed records of their activities and services, and health outcomes in their respective areas.
These data are reported to the district/sub-district health centers (puskesmas), which are then
reported to district officials, and forwarded to provincial officials for consolidation and reporting to
the Ministry of Health. Districts compile their reports quarterly; provinces compile reports annually
and submit to central level annually.
The reproductive health information system (HIS) datasets from the districts/provinces used in
these profiles are from 2005. These data are reported in excel format on five separate worksheets. They outline data at district level providing provincial totals and simple indicator calculations. Data include demographics (population, pregnancies, deliveries, newborn born), number
of people who received services according to a range of indicators relevant to reproductive health
and national targets, health facilities, health personnel, maternal and neonatal deaths, stillbirths,
causes of maternal death, and timing of neonatal death.
Public and private hospitals report directly to the province. Hospital data is not compiled by district; only provincial totals are calculated. The hospital HIS data relevant to reproductive health
includes total births in hospital, total complications managed, by type of complication (bleeding,

Provincial Reproductive Health & MPS Profile of Indonesia

INTRODUCTION
infection, eclampsia, abortion, other), c-sections, and mortality by cause. Hospital data is compiled at central level, and availability of these data can be delayed. The most recently compiled
hospital database available for these profiles is from 2004.

mortality, and early neonatal mortality (<7 days) accounts for 78% of neonatal mortality (50% of
infant mortality). This predominance of perinatal risk, compared to other causes of death, even
impacts the primary causes of all deaths at any age: Perinatal conditions is now one of the top
ten causes of mortality in Indonesia, rivaling heart disease and diabetes combined.

Health Indicators and Outcomes

Reducing maternal mortality is one of the highest priorities in the area of reproductive health
in Indonesia. Recent estimates of the maternal mortality ratio range from 230 to 307 maternal
deaths per 100,000 live births. Indonesian women face one of the highest risks of maternal death
among developing countries in the East Asia/Pacific region. The MMR has likely been reduced in
the past 20-30 years some estimates suggest it was over 600 in 1990.10 However, the most recent IDHS could not conclude that the estimated rate of 307 (for period 1998-2002) had declined
significantly in the past 10-15 years.

Despite an average annual economic growth rate of 5%, Indonesias social indicators reflect
considerable inequity. Nearly 17% of all Indonesians are classified as below the poverty line
(about IDR 4000/day/capita), but poverty rates by region range from 10% in Kalimantan to 31%
in Maluku/Papua. An estimated 49% of Indonesians live on less than USD 2 per day (IDR
18,000). Adult female literacy is relatively high at 87%, ranging from 68% in Papua to 99% in
North Sulawesi.
Although communicable diseases remain the main cause of mortality, Indonesia is also experiencing an epidemiological transition driven by a higher prevalence of non-communicable, lifestyle related diseases. The proportion of smokers is steadily increasing all over Asia, particularly
among young people. In 2003, over 1 in 5 Indonesians were estimated to smoke daily. In contrast, only 3 out of 4 (77%) Indonesians have access to safe water (91% in urban areas; 67% in
rural areas).
Economic development and social investment has facilitated a significant decline in both the
infant and under-5 mortality rates over the past 30 years. Current estimates are 28 infant deaths
(<1 year), and 38 child deaths (<5 years) for every 1000 newborn born alive. These have declined 65-70% since 1980. However, with this decline comes a change in the proportion of adult
and child deaths attributable to perinatal causes. Neonatal mortality accounts for 64% of infant

Country

MMR (WHO/UNICEF/UNFPA, 2000


estimates)1

Indonesia

230

Cambodia

450

China

56

Malaysia

41

Mongolia

110

Myanmar/Burma

360

Philippines

200

Thailand

44

Vietnam

130

There is great disparity in these key health outcome indicators within the population. The under-5
mortality rate is 77/1000 live births in the poorest wealth quintile, and only 22 in the richest. The
ratio of those two rates (3.5) reflects greater disparity in this health outcome according to wealth
than the Philippines or Vietnam. The maternal mortality ratio is more than twice the rate among
the poorest quintile compared to the richest quintile. The poorest 20% of the population are
estimated to have an MMR or over 700, while the richest 20% are estimated to have an MMR
of just over 200. The two poorest quintiles combined, representing 40% of the total population,
experience an MMR of about 600 or higher.
Predominant causes of maternal deaths are hemorrhage, hypertensive disorders (eclampsia),
and infection. Among neonatal deaths, the major causes include infection (27%), birth asphyxia
(23%) and preterm birth (30%).
Nine out of ten pregnant women in Indonesia seek antenatal care and rates of delivery with a
skilled attendant have increased significantly in recent years. Over 80% of women who had a live
birth in the past 5 years received antenatal care from a midwife, and another 10% from a doctor.
Just over 8% reported having no antenatal care or antenatal care from a traditional birth attendant
only. There are also relatively high rates of early antenatal visits (>60% in 1st trimester), and 4 or
more visits (>80%).11
Delivery services are predominantly provided through the private sector. Less than 10% of
women delivering a live birth in the last 5 years were delivered in a public health facility. Over
30% were delivered in a private health facility, and nearly 60% at home. Skilled attendance
at delivery has been increasing, but over 33% of women are still delivered by a TBA, relative
or nobody; 55% are delivered by a private midwife (village based, or private practitioner), and
11% by a doctor or specialist. Birth registration remains sub-optimal at about 54%, the primary
barrier being cost.12

 Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS


 Wikipedia, accessed April 26 2007
 BPS, 2006
 National Institute of Health Research and Development and Ministry of Health, Indonesia: Sub-national Health System Performance Assessment, 2005
 WHO 2006, Mortality Country Fact Sheet (http://www.who.int/whosis/mort/profiles/mort_searo_idn_indonesia.pdf )
 Author calculation, 1980 data from World Bank paper on health decentralization (http://siteresources.worldbank.org/INTEAPDECEN/Resources/Chapter-8.pdf )

Overview of Provincial Reproductive Health Profiles


 WHO 2006 Neonatal and Perinatal Mortality: Country, Regional and Global Estimates
 WHO 2006, Mortality Country Fact Sheet
10 http://www.unfpa.org/news/news.cfm?ID=670
11 Indonesian Demographic Health Survey, 2002/3
12 IDHS, 2002/03

Provincial Reproductive Health & MPS Profile of Indonesia

INTRODUCTION
Provincial reproductive health profiles were prepared using HIS data reported by each province
from 2001-2005, and hospital datasets of 2001 and 2004. The following categories were reviewed
in each province: Health facilities, number of basic and comprehensive emergency obstetric care
facilities, health personnel, antenatal care coverage, skilled birth attendance coverage, postnatal/
neonatal care coverage, maternal and neonatal deaths and hospital-level statistics on obstetric
complications, c-sections, and maternal mortality.
The 2005 dataset was described in the most detail. Health personnel were described using both
2001 and 2005 datasets to detect increasing or decreasing trends in coverage over time. Antenatal attendance of at least four visits (K4), skilled birth attendance, and maternal mortality was
assessed for all years between 2001 and 2005 (where data were reported). A final summary table
of key indicators was prepared to compare key indicators in 2001, 2005, and national targets for
2007 and 2010.
All tables were formulated in order to describe the data in a standardized manner for each province (though some adjustments were made for some provinces due to data omissions) and to
enable provincial comparisons of selected indicators.

Districts or provinces may also wish to review their HIS reports on an ongoing basis, from 2006
and later, to correct problems in data quality or consistency, and identify potential service gaps.
Increased utilization of data to provide feedback to health workers and to assist in health planning
should lead to better quality data being collected, and better-directed health resources to problem
areas. Provincial health officials who can link hospital and provincial data will also be in a better
position to contribute to a more integrated and effectively implemented reproductive health program overall. Quality of care, and accessibility and responsiveness of hospitals to the community
is central to improving access to emergency obstetric/neonatal care which will lead to reductions
in maternal and neonatal mortality.

Health Facilities and Personnel

A Note on Data Quality


The overall data quality of health facility and health personnel reports was poor. Almost every
province submitted incomplete data on some or all of these indicators, for some or all districts.
Data on demographic events (population, pregnancies, deliveries and newborn born), and services provided was generally more complete than data on health infrastructure. However, detection
of pregnancy risk and management of complications was less accurate and complete compared
to more basic (and perhaps more easily defined) indicators such as antenatal care and birth attendance.
Mortality data also appeared to be poor. Maternal mortality ratios calculated for each year did not
show interesting or believable trends. Stillbirths and neonatal deaths were significantly underreported by all provinces. Based on estimates, HIS reported maternal deaths likely represented
only as much as half of expected deaths, and stillbirths/neonatal deaths maybe one-third or fewer.
Provincial estimates of mortality rates were not available, therefore it was impossible to even estimate which provinces may have under-reported more or less than the others. It is also not likely
that the same rate of under-reporting applies to all districts.
This variability in reporting completeness and quality makes it very difficult to draw any valid conclusions from comparing provinces to one-another. Although these data are presented in each
profile, and provincial comparisons are compiled in this chapter, extreme caution is advised in
their interpretation. More valid conclusions may be drawn from regional-level comparisons (i.e.
Java compared to Sumatra).
Due to the inability to verify the data quality at the district and even the provincial level, caution is
also advised in interpreting the meaning of individual provinces or districts highlighted as under-

10

performers on specific indicators. Sometimes, certain areas will repeatedly appear as having
low coverage which likely reflects real problems in those areas. Other times, areas may appear
as under-performers simply because of errors or omissions in their HIS data reports. All areas
highlighted as being at particular risk should be investigated more closely and directly through site
visits to those areas, situational analyses, and meetings with health providers and health officials
for a more accurate picture of health status in those communities.

Health facility data includes both public and private hospitals, hospitals with specialists (obstetrics
and pediatrics), puskesmas, puskesmas with doctors, puskesmas with beds, and puskesmas that
have received training in basic emergency obstetric care (BEONC, or PONED).
BEONC training involves three people from each puskesmas (doctor, nurse, and midwife) and
covers topics such as pre-eclampsia, shoulder dystocia, vacuum extraction, postpartum hemorrhage, postpartum fever, management of low birth weight newborn, hypoglycemia, icterus/hyperbilirubin, feeding problems, asphyxia, respiratory problems, neonatal (LBW) convulsion, referral
and transportation. The training is seven days long and costs IDR 9.3 million for three persons
(one facility).
Health personnel data includes total specialists (obstetrics, pediatrics), total general practitioners,
ANC trained nurses, total midwives and key characteristics of midwives. One of these characteristics is APN training which prepares individual midwives (including private practitioners) in active
management of 3rd stage of labor, management of hemorrhage and neonatal asphyxia. The training is 10 days long and includes a clinical practicum. It costs IDR 4.4 million per midwife. The aim
is to concentrate training on skill areas most likely to reduce maternal and neonatal mortality.
Compilation Figure 3 shows the proportion of villages with a bidan di desa, and proportion of
midwives who have received APN training. Most provinces have bidan di desa coverage of less
than 60%, and the level of APN training is low.
Figure 4 describes the proportion of all puskesmas with beds, and the proportion of all puskesmas
who have received BEONC training. This figure shows that most provinces have not succeeded
in providing the skills to all health teams working at puskesmas likely to provide delivery care.

Provincial Reproductive Health & MPS Profile of Indonesia

INTRODUCTION
Table 1 ranks provinces on the proportion of APN trained midwives, and the proportion of BEONC
puskesmas, as a percentage of all midwives and all puskesmas, respectively.
Table 1. Provinces by rank according to APN training and BEONC puskesmas
% midwives with APN training
% BEONC puskesmas
Worst ranking provinces (<10% coverage)
Papua
0
Gorontalo
Bengkulu
1
North Sumatra
Gorontalo
1
Jambi
Riau
2
Bengkulu
DKI Jakarta
3
Bangka Belitung
West Kalimantan
4
West Java
South Kalimantan
5
West Kalimantan
South Sumatra
6
Southeast Sulawesi
Jambi
7
Banten
Moderate provinces (20-24% coverage)
Central Sulawesi
10
DKI Jakarta
North Maluku
10
East Java
West Papua
10
South Sulawesi
Aceh
11
Aceh
Central Java
11
Yogyakarta
North Sulawesi
13
Lampung
East Sulawesi
13
Central Java
Maluku
13
Bali
Yogyakarta
14
East Nusa Tenggara
East Nusa Tenggara
14
Kep. Riau
West Kalimantan
15
Riau
Bali
15
South Sumatra
West Nusa Tenggara
17
West Java
19
Best ranking provinces (25% coverage, or above)
Banten
23
North Sulawesi
Bangka Belitung
33
West Sumatra
South Sulawesi
36
Maluku
East Java
43
Central Sulawesi
Southeast Sulawesi
89
West Nusa Tenggara
Non reporting provinces
North Sumatra
-Central Kalimantan
West Sumatra
-East Kalimantan
Kep. Riau
-South Kalimantan
Lampung
-West Sulawesi
East Kalimantan
-North Maluku
Papua
West Papua

0
3
4
4
6
8
8
8
9
10
11
11
13
13
15
16
17
18
20
21
23

25
30
31
37
74
--------

Provincial Reproductive Health & MPS Profile of Indonesia

11

INTRODUCTION
Figure 3. Proportion of all villages with midwife living in village, and proportion of all
midwives with APN training, by province (HIS 2005; data not reported by all provinces)
100
90
80
70
60
50
40
30
20
10

% villages with live in midwife

Primary Health Care Indicators: Methodology Note


All indicators rely on the accuracy of numerators and denominators to reflect a true picture of
health service coverage. At the national level, the MOH has standard formulas to estimate the
number of pregnancies and deliveries in the country overall. The smaller the areas such formulas
are applied to, however, the less accurate the resulting estimates become because their accuracy
relies on a provincial estimate of the crude birth rate (CBR). The most recently available provincial estimates for CBR were from 2000 (BPS), and they varied substantially by province. CBRs
could be calculated from reported newborn/reported population, but that would not allow for an
independent assessment of the accuracy of those reported events by province in HIS data.
Therefore, CBR estimates from 2000 were used for 26 provinces to calculate estimated pregnancies and deliveries. CBRs from host provinces were applied to seven additional provinces that

12

AL
U
K
M U
AL
U
PA T
P
IR UA
JA
BA
R

BA
LI
N
TB
NT
T

SU
SU LU
LT T
E
SU NG
LS
SU EL
LT
R
G SU A
O
L
R BA
O
N R
TA
LO

KA
L
KA BA
LT R
EN
KA G
LT
KA IM
LS
EL

TE
JA N
BA
R
D
JA K
TE I
N
G
D
IY
JA
TI
M

BA
N

U
T
BA
KE R
PR
I
RI
AU
JA
SU MB
M I
SE
L
BE BAB
N
EL
G
LA KU
M LU
PU
N
G

SU

SU

N
AD

% midwives with APN training

are now separate (Kepri/Riau, Bangka Belitung/South Sumatra, Banten/West Java, Gorontalo/
North Sulawesi, West Sulawesi/South Sulawesi, North Maluku/Maluku, and West Papua/Papua).
The overall country CBR was 22.2, but the range was from 16.9 (Yogyakarta) to 27.8 (Papua).
The ratio of reported to calculated events was used to evaluate the accuracy of reported events.
Over the whole country, the ratio of reported to estimated pregnancies was 100.8, and reported
deliveries/estimated deliveries was 100.7, which means that reported events were quite accurate overall. Three-quarters of all provinces had reported/estimated ratios between 95 and 105
indicating relatively high accuracy of counted events, and little bias toward under-counting or
over-counting.
The ratio of reported to estimated events was evaluated for each district in each province to determine if the province had systematically calculated those events using a standard multiplier or

Provincial Reproductive Health & MPS Profile of Indonesia

INTRODUCTION
Figure 4. Proportion of all puskesmas with beds, and proportion puskesmas with BEONC
training, by province (HIS 2005; data not reported by all provinces)
100
90
80
70
60
50
40
30
20
10
0

I
I
L
L
T
AD U BAR PR IAU MB SE BE ULU NG
N
M
E
R
A
M BA GK PU
U
M
J
K
S
SU
N AM
SU
L
BE

R KI
N
G IY I M
TE BA D E N D AT
A
N
T
J
J
JA
BA

% puskesmas with beds

not. Only one province, East Java, appeared to do this. A few minor errors were also identified
during this process. West Sumatra did not submit population or delivery data, so deliveries were
estimated according to reported pregnancies (94.7%). Maluku submitted pregnancy and delivery
data that reflected very large errors in several districts (under and over-reporting), so estimated
pregnancies and deliveries were calculated using standard MOH formulas. North Sumatra and
South Sumatra had obvious errors in one district, each, so events for those district only were
estimated. The remaining 28 provinces appeared to submit actual counts of pregnancies and deliveries that appeared valid and consistent with expectations and with one-another (see Appendix
for more detail on data corrections).
There is no standard MOH formula for determining the expected number of newborn born according to total population, pregnancies or deliveries. Therefore, this was calculated using 2005 data
from the country overall. Each provincial report of newborn was first evaluated according to re-

R
G IM EL
BA EN LT LS
L
T
A A
KA AL K K
K

L
T G
R O
A
LU E N LSE LTR BA AL
L NT
SU LT SU SU
SU O
SU
R
O
G

LI TB TT
N
BA N

T
A
R
KU U
U AL P U ABA
L
A
J
A
M P R
M
I

% Puskesmas trained in BEONC

ported deliveries. Four provinces were excluded from the multiplier calculation due to substantial
errors in one or more districts, or lack of reporting delivery data altogether. Three provinces were
excluded because reported newborn were either the same or greater than reported deliveries.
The data from the remaining 26 provinces was totaled, and the proportion of newborn to deliveries
was calculated (96.2%). This multiplier was then used to estimate reported newborn, by district,
in the four provinces that reported invalid data, and to make other minor corrections to reported
newborn in three additional provinces.
Overall, an average of 2.4% of the population was reported to be pregnant in 2005 (range: 1.6 in
Yogyakarta to 3.0 in Riau).

Antenatal Care Coverage

Provincial Reproductive Health & MPS Profile of Indonesia

13

INTRODUCTION
Table 2. Proportion of pregnant women who attend 4 visits of antenatal care, and proportion of women who attend some ANC, but not the full 4 visits
Difference between
At least 4 ANC visits (K4)
K4 and K1 (women with <4 visits, but
some ANC)
Worst ranking provinces (Below 70% K4; 15% or above in K1-K4)
Papua
30
Nusa Tenggara Timur
27
Irian Jaya Barat
51
Irian Jaya Barat
22
Sulawesi Barat
56
Sulawesi Selatan
19
Maluku
65
Maluku
18
Nusa Tenggara Timur
66
Banten
17
D.I Yogyakarta
16
Kalimantan Selatan
16
Kepri
15
DKI
15
Papua
15
Moderate provinces (Above 70% coverage; below 15% difference)
Sulawesi Selatan
70
Maluku Utara
14
Sulawesi Tenggara
70
Jambi
13
Nanggroe Aceh Darussalam
72
Jawa Timur
13
Banten
72
Sulawesi Utara
13
Maluku Utara
72
Kalimantan Tengah
12
Bengkulu
74
Sulawesi Tenggara
12
Kalimantan Selatan
75
Gorontalo
12
DKI
76
Kalimantan Timur
11
Kalimantan Barat
76
Sumatera Barat
10
Jawa Barat
77
Kalimantan Barat
10
Jawa Timur
77
Nanggroe Aceh Darussalam
9
Jambi
78
Riau
9
Kalimantan Tengah
78
Jawa Barat
9
Kalimantan Timur
78
Jawa Tengah
9
Sulawesi Utara
78
Sulawesi Tengah
9
Sulawesi Tengah
78
Lampung
8
Jawa Tengah
79
Nusa Tenggara Barat
7
Gorontalo
79
Sumatera Selatan
6
Sumatera Utara
80
Bengkulu
6
Sumatera Barat
81
Sulawesi Barat
6
D.I Yogyakarta
82
Sumatera Utara
3
Kepri
83
Bangka Belitung
2
Nusa Tenggara Barat
83
Non reporting: Bali
-Provinces meeting 2007 target for K4 (84% or above)
Riau
84
Lampung
85
Sumatera Selatan
86
Bali
87
Bangka Belitung
91

14

Key concepts in evaluating antenatal care coverage are access and retention. Access is measured by the K1 indicator (referred to as ANC1 in the profiles) which measures the proportion of
pregnant women who have completed at least one antenatal visit. Retention is measured by the
K4 indicator (ANC4) which measures the proportion of pregnant women who have completed at
least four antenatal visits, the standard recommendation for pregnant women not experiencing
any complication or sign of illness/risk. The difference between K1 and K4 reflects the level of
missed opportunities to the health care system these are the women who proved to be able to
access care, but did not comply with the recommended number of visits. This difference reflects
potential gaps in quality of care and potential benefits to closing those gaps.
Figure 5 shows the K4 coverage and K1-K4 difference by province. The majority of provinces
range between 70-80% for K4 coverage. The difference between access (K1) and retention
(K4) ranges from 5% to over 20%. Overall access (K1) can be estimated by adding the difference to the K4 bar. Most provinces have good access to antenatal care, but vary more in their
performance on keeping women in the antenatal care system throughout pregnancy. Table 2
ranks provinces according to these two indicators. Only five provinces met or exceeded the 2007
national target for K4 (84%).

Skilled Birth Attendance


Increasing the proportion of women who are delivered by a skilled health professional is probably the most important first step toward
Estimated rates of % SBA coverage and %
reducing maternal and early neonatal mordeliveries at health facilities in 1997 and
tality in any country. Insuring that those
2002 IDHS surveys
skilled birth attendants are well trained,
66
70
have necessary equipment, practice infec60
tion control and other basic skills, and are
43
50
40
supported by a functional referral network
40
30
including transportation and hospital ac21
20
cess are also critical factors. However, the
10
effectiveness of all of these quality of care
0
% SBA
% health facility
components depends first on whether
women are using skilled birth attendants.
IDHS 1997/98 IDHS 2002/03
The last two demographic health surveys
shows that the national estimates of the rates of SBA coverage (doctor, nurse or midwife attending) and deliveries at a health facility (public or private) have increased substantially between
1997 and 2002. HIS data from 2005 support this estimated increase in SBA coverage, with 22
provinces reporting rates at 70% or higher (see Table 3 and Figure 6).

Postnatal (Neonatal) Care Coverage

Provincial Reproductive Health & MPS Profile of Indonesia

INTRODUCTION
This indicator measures both maternal postpartum access to care, and neonatal care. The timing of the KN1 visit should be with 2 days of birth/delivery, and the KN2 visit before 28 days
postpartum. There may be some lack of precision in this indicators definition and understanding
in the field, and in the actual services provided at KN visits. It is likely that many visits are focused
on the neonate rather than the postpartum mother, and that important signs of maternal illness or
risk in the mother could easily be missed by the health system as a result. In 2002/3, the IDHS
reported data somewhat outside of the definition of this indicator, however, 62% attended a postnatal checkup within 2 days of delivery, and 17.5% did not attend any postnatal care.
HIS data from 2005 is reported in Table 3 by province. Generally, the rate of KN1 is higher than
the IDHS estimate of 2002 in most provinces.

Table 3. SBA and KN1 coverage


Coverage of deliveries with a skilled birth
Coverage of 1st postnatal / neonatal visit
attendant
Worst ranking provinces (SBA or KN1 coverage <70%)
30
24
Papua
Papua
50
48
Irian Jaya Barat
Maluku
52
57
Kalimantan Barat
Sulawesi Barat
56
59
Maluku
Irian Jaya Barat
58
63
Sulawesi Barat
Nanggroe Aceh Darussalam
60
Moderate coverage (KN1 70% -82%)
Maluku Utara
63
75
Banten
Sumatera Utara
66
76
Kalimantan Barat
Maluku Utara
67
77
Jawa Barat
Bengkulu
67
77
Nusa Tenggara Timur
Sulawesi Selatan
69
78
Sulawesi Selatan
Sulawesi Tengah
78
Sulawesi
Tenggara
Moderate coverage (SBA 70% - 81%)
70
79
Bengkulu
Nusa Tenggara Timur
70
80
DKI
Jawa Barat
70
81
Sulawesi Tenggara
Jambi
71
82
Gorontalo
DKI
72
82
Riau
Kalimantan Timur
73
82
Kalimantan Timur
Sulawesi Utara
74
-Sumatera Utara
Not reporting: Aceh (NAD)
74
KN1 coverage meets 2007 target
Lampung
(83% or above)
74
Sulawesi Tengah
75
83
Kalimantan Tengah
Riau
76
83
Nusa Tenggara Barat
Lampung
77
83
Jawa Tengah
Kalimantan Tengah
78
83
Sumatera Barat
Gorontalo
78
83
Jambi
Nusa Tenggara Barat
81
84
Kepri
Banten
81
85
Kalimantan Selatan
Sumatera Selatan
81
85
Sulawesi Utara
Jawa Tengah
86
SBA coverage meets 2007 target
Sumatera Barat
(82% or above)
86
Kepri
Sumatera Selatan
82
86
D.I Yogyakarta
Jawa Timur
82
87
Jawa Timur
D.I Yogyakarta
83
87
Kalimantan Selatan
Bangka Belitung
84
92
Bangka Belitung
Bali
89
95
Bali

Provincial Reproductive Health & MPS Profile of Indonesia

15

INTRODUCTION
Figure 6. Proportion (%) of all deliveries attended by a skilled health provider,
by province (HIS 2005)
100
90
80
70
60
50
40
30
20
10

M
AL
U
M KU
AL
PA UT
IR P U
JA A
BA
R

BA
LI
N
TB
N
TT

S
SU UL
LT U T
E
SU NG
LS
SU E
LT L
G SU RA
O
R LB
O A
N R
TA
LO

N
SU A D
SU MU
M T
BA
KE R
PR
R I
IA
JA U
SU MB
M I
SE
BE BA L
N BE
G L
LA KU
M LU
PU
NG
BA
N
TE
JA N
BA
R
JA DK
TE I
N
G
D
JA IY
TI
M
KA
KA LBA
LT R
E
KA NG
L
KA TIM
LS
EL

Maternal and Neonatal Deaths


A total of 4169 maternal deaths were reported for 2005 in Indonesia, or only 87 / 100,000 estimated live births. This current MMR based on actual reported deaths is less than half of the
lowest current estimate of the MMR in Indonesia. The WHO/UNICEF/UNFPA estimates the MMR
to be 230; the most recent estimate from the IDHS was 307 (2002/3).

deaths) which describe the proportion of all maternal deaths contributed by each region. For example, 20.7% of all maternal deaths occurred in Sumatra region in 2005 (or
207/1000 reported deaths). Java accounted for over 46% of all deaths, Kalimantan only
5.5%, Sulawesi 11%, Bali/Nusa Tenggara 11% and Maluku/Papua 5%.

Figure 7 shows maternal mortality ratios from the years 2001-2004 are similarly under-reported
by about 60%. A slight decline is observed from 2004, but with substantial rates of under-reporting, continued reporting errors cannot be ruled out as an explanation for the observed reduction
in MMR.

Figure 9 shows each provinces maternal mortality ratio, with summary ratios calculated
for each region. There is significant variability in MMRs within all regions except Kalimantan. Table 5 ranks each province by MMR: East Nusa Tenggara, Maluku, Kepri, North
Maluku and Gorontalo have the highest reported MMR (>200). These five provinces
represent four different regions, under-scoring the diversity of the country with regard to
health indicators and access to quality care.

Table 4 ranks all provinces by total number of reported deaths through the HIS in 2005. Figure 8
shows each provinces total number of reported deaths, with summary totals (per 1000 reported

16

Provincial Reproductive Health & MPS Profile of Indonesia

INTRODUCTION
Figure 5. Proportion (%) of pregnant women who attend the 4th antenatal visit (K4),
and % who attend some antenatal care, but not the recommended four visits (K1-K4),
by province (HIS 2005)
100
90
80
70
60
50
40
30
20
10

k4

The regional MMRs show that Maluku/Papua has the highest MMR at 188, followed by Bali/Nusa
Tenggara (170) and Sulawesi (122). Kalimantan and Sumatra have similar ratios (78 and 80
respectively). Java has the lowest reported MMR at 74, although the island accounts for nearly
half of all deaths due to the fact that 58% of the population of Indonesia lives on Java.
Hospital data report maternal deaths that occur in hospital. The proportion of maternal deaths
in hospital is a crude measure of the accessibility of hospitals in the event of an obstetric emergency. If a higher proportion of maternal deaths are occurring in hospital, this likely means that
women having a complication during pregnancy or delivery were able to access tertiary care prior
to death. The timing of access would be important to further understand this indicator. If most
women who died are accessing too late for the hospital to effectively intervene, then midwives
skills, referral and transportation systems should be reviewed. If most women who died were
actually delivered in hospital, then the quality of care at hospitals should be reviewed further
(training, skills, staffing, equipment, quality assurance, etc.).

AL
U
K
M U
AL
U
PA T
P
IR UA
JA
BA
R

BA
LI
N
TB
NT
T

SU
SU LU
LT T
E
SU NG
LS
SU EL
LT
R
G SU A
O
L
R BA
O
N R
TA
LO

KA
L
KA BA
LT R
EN
KA G
LT
KA IM
LS
EL

TE
JA N
BA
R
D
JA K
TE I
N
G
D
IY
JA
TI
M

BA
N

U
T
BA
KE R
PR
I
RI
AU
JA
SU MB
M I
SE
L
BE BAB
N
EL
G
LA KU
M LU
PU
N
G

SU

SU

N
AD

k1-k4

Figure 10 shows this indicator (hospital deaths 2004 / all reported deaths in 2004) by province. It
ranges from zero to over 80%. Table 6 ranks all provinces by the proportion of reported deaths
occurring in hospital. Eleven provinces were below 10%, and only three provinces were above
50%. This indicator could not be calculated for 8 provinces due to missing 2004 maternal mortality reports from either the hospital or the community, or both. When these rankings are compared
to actual MMR (Table 5), 7 of 11 worst ranked provinces had MMRs over 100, while only 4 of 11
moderately ranked provinces had MMRs over 100. This suggests that this indicator has some
validity in evaluating progress toward reducing maternal mortality. However, caution is advised in
over-interpreting this indicator. This measure is highly subject to error if hospital data are incomplete, which they likely are.
Reported causes of maternal deaths support international data citing hemorrhage as the leading
cause. Eclampsia is the 2nd leading cause of death in almost every province. Infection gener-

Provincial Reproductive Health & MPS Profile of Indonesia

17

INTRODUCTION
Table 4. Reported Maternal Deaths, HIS 2005
Worst ranking provinces (>200)
Jawa Tengah
631
Jawa Barat
624
Jawa Timur
413
Nusa Tenggara Timur
330
Other provinces
Sulawesi Selatan
163
Riau
157
Banten
157
Sumatera Utara
135
Nanggroe Aceh Darussalam
117
Sumatera Barat
110
Nusa Tenggara Barat
108
Sulawesi Tengah
89
Kepri
88
Lampung
84
Maluku
77
Papua
75
DKI
70
Kalimantan Barat
70
Sulawesi Utara
69
Sulawesi Tenggara
62
Jambi
60
Kalimantan Selatan
59
Kalimantan Timur
58
Sumatera Selatan
54
Maluku Utara
46
Gorontalo
45
Kalimantan Tengah
42
D.I Yogyakarta
39
Bali
35
Bangka Belitung
30
Sulawesi Barat
29
Bengkulu
26
Irian Jaya Barat
17

Figure 7. Maternal Mortality Ratio (reported deaths / 100,000 estimated live births), 2001-05
compared to MMR estimates from WHO/UNICEF (2006) and IDHS (2002/3)

350

307

307

300
250
200
230

150

230

230

230

230

100
50
0

IDHS estimate

100

97

97

82

87

WHO/UNICEF estimate
MMR

2001

ally accounts for a very small proportion of


deaths, though it may be more under-reported than other causes due to difficulty in
diagnosing infection as a primary cause of
death in cases occurring in the community.
The biggest concern about these data (see
Figure 11); however, is the very high rate of
unattributed maternal deaths to other or
unknown causes. This is equally true of
hospital data where there should be a far
TOTAL
4169
higher proportion of deaths attributed to an
underlying causes than actually observed in most provincial hospital reports.
In summary, because there is consistent evidence of under-reporting of maternal deaths in all
provinces, and no guarantee that provinces under-report at similar rates, extreme caution is advised in over-interpreting these reported rates of maternal mortality. Key interpretations of the
above data that are most likely to be valid are:

18

307

307

307

2002

2003

2004

2005

Under-reporting maternal mortality is a significant problem in all provinces.

There is no evidence of any significant decline in maternal mortality since 2001.

The largest number of maternal deaths occurs in Java, though the individual risk of death per
woman in Java may be lower than other regions of Indonesia.

Women living in Maluku/Papua region, and East or West Nusa Tenggara (not Bali) face the
highest individual risk of maternal death.

These disparities in maternal mortality rates by region (and province) suggest that different
provinces may require different interventions to further reduce maternal mortality. Provincial
level situation analyses of factors contributing to maternal mortality should be under-taken.

The rate of deaths occurring in hospital as a proportion of all maternal deaths may be an impor-

tant indicator to monitor as a measure of access to emergency obstetric care.

Provincial Reproductive Health & MPS Profile of Indonesia

INTRODUCTION
Figure 8. Maternal deaths (HIS 2005), by province and
regional proportion of every 1000 reported deaths (brown bars)
700

600

500

464

400

300

200

207
110

100

55

113
52

NA
SU D
M
SU UT
MB
AR
KE
PR
I
RIA
U
JA
MB
SU
MS I
EL
B
BE ABE
NG
L
K
LA ULU
MP
UN
G
Su
ma
t
r
BA
a
NT
EN
JA
BA
R
DK
JA
TE I
NG
DIY
JA
TI M
Ja
KA va
L
KA BAR
LT
EN
KA G
LT
KA IM
L
S
Ka
lim EL
an
ta
SU n
SU LUT
LT
E
S U NG
LS
SU EL
LT
R
GO SULB A
RO
A
NT R
AL
O
Su
law
es
i
BA
LI
Ba
NT
li, N
B
us
a T NT
T
en
gg
a
ra
MA
LU
KU
MA
LU
PA T
PU
Ma IRJA A
BA
luk
R
u,
Pa
pu
a

Community and health providers (including those in hospital) may be poorly trained in assigning

a likely cause of maternal death. Further efforts should be directed toward ensuring higher level
medical review of a significant proportion of maternal deaths as part of better understanding
risks and opportunities for prevention.

Hospital Management of Maternal and Neonatal Complications


Hospital data show that most pregnant women treated in hospital are classified as complicated
cases. Complicated deliveries were reported by cause: bleeding, eclampsia, infection, abortion,
or other. Deliveries counted only in the c-section column of the data report (thus, not assigned
to an underlying reason for the c-section) were not counted as complicated. The proportion of
hospital deliveries classified as complicated ranged from less than 8% in the Maluku Islands to
74% in Jambi and West Papua (89%). Nearly three-quarters (24) of all provinces reported rates
between 40 and 65%. It is clear that most hospitals primarily manage complicated deliveries, and

Provincial Reproductive Health & MPS Profile of Indonesia

19

INTRODUCTION
Figure 9. Maternal Mortality Ratio, by province (HIS 2005)
(reported deaths / 100,000 reported newborn), and
MMR by region (brown bars; rep dths / 100,000 estimated live births)

Table 5. Maternal Mortality Ratio (reported maternal


deaths / 100,000 estimated live births, HIS
2005)

300

250

200

188
170

150

122
100

78

74

80

50

NA
SU D
M
SU UT
MB
AR
KE
PR
I
RIA
U
JA
MB
SU
MS I
EL
B
BE ABE
NG
L
K
LA ULU
MP
U
Su NG
m
BA atra
NT
E
JA N
BA
R
DK
JA
TE I
NG
DIY
JA
TI M
Ja
KA va
L
KA BAR
LT
EN
KA G
LT
KA IM
Ka LSE
L
lim
an
tan
SU
SU LUT
LT
E
S U NG
LS
SU EL
LT
R
GO SULB A
RO
A
NT R
AL
O
Su
law
es
i
BA
LI
Ba
NT
li,
B
Nu
sa
Te NTT
ng
g
MA ara
LU
K
MA U
LU
PA T
PU
Ma IRJA A
BA
luk
R
u,
Pa
pu
a

Worst ranking provinces (>200)


Nusa Tenggara Timur
300
Maluku
258
Kepri
255
Maluku Utara
221
Moderate provinces (from 60-200)
Papua
169
Sulawesi Tengah
164
Sulawesi Utara
160
Riau
134
Sulawesi Tenggara
129
Sulawesi Barat
128
Bangka Belitung
121
Sumatera Barat
115
Nanggroe Aceh Darussalam
109
Jawa Tengah
106
Irian Jaya Barat
105
Nusa Tenggara Barat
104
Sulawesi Selatan
97
Jambi
96
Kalimantan Tengah
89
Kalimantan Timur
88
D.I Yogyakarta
83
Kalimantan Selatan
80
Kalimantan Barat
72
Jawa Barat
68
Banten
67
Jawa Timur
65
Bengkulu
60
Best ranking provinces (below 60)
Bali
56
Lampung
52
Sumatera Utara
46
DKI
33
Sumatera Selatan
29
TOTAL

20

Provincial Reproductive Health & MPS Profile of Indonesia

87

INTRODUCTION
Figure 10. Estimated proportion (%) of all maternal deaths occurring in hospital
(HIS 2004 reported deaths as proportion of 2004 hospital data reports of deaths;
non-reporting districts excluded)
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0

Provincial Reproductive Health & MPS Profile of Indonesia

M
AL
U
K
PA U
PU
A

N
TT

LI
N
TB

BA

SU
SU LU
LT T
E
N
SU G
LT
R
A

KA
LB
KA AR
LT
EN
KA G
LT
KA IM
LS
EL

D
IY
JA
TI
M

BA
N

TE
N
JA
BA
JA R
TE
N
G

0.0
N
A
SU D
M
U
T
KE
PR
I
R
IA
U
JA
M
SU B I
M
SE
BA L
LA BE
L
M
PU
N
G

Table 6. Percent of maternal deaths (2004) occurring in hospital


Worst ranking provinces (<10% coverage)
Bangka Belitung
0.0
Kalimantan Selatan
2.3
Maluku
4.0
Riau
4.1
Nanggroe Aceh Darussalam
4.3
Lampung
4.8
Nusa Tenggara Timur
6.5
Kalimantan Timur
7.6
Jawa Barat
8.3
Nusa Tenggara Barat
8.5
Sulawesi Utara
9.6
Moderate provinces (20% - 49% coverage)
Kalimantan Tengah
10.0
Sulawesi Tenggara
10.9
Kalimantan Barat
13.8
Sulawesi Tengah
14.2
Papua
14.6
Kepri
17.9
Jambi
20.5
Sumatera Selatan
25.0
Bali
25.4
Banten
28.1
Jawa Timur
39.9
Best ranking provinces (50% coverage, or above)
Sumatera Utara
54.5
Jawa Tengah
63.4
D.I Yogyakarta
81.8
Non reporting provinces
Sumatera Barat
-Bengkulu
-DKI
-Sulawesi Selatan
-Sulawesi Barat
-Gorontalo
-Maluku Utara
-Irian Jaya Barat
--

21

INTRODUCTION
Figure 11. Causes of maternal deaths as proportion (%) of total reported deaths,
by province (HIS 2005)
100%
90%

20
38 36

80%

28

17

22
33

36
50

32

27

42

36

21 22
36

20

24
29 26

37

39

37 36

26
41

49

56

70%

14

60%
50%
40%
30%
20%
10%
0%

52

48

41 38

43

40 41

26

52

52
39

27

37

36

43

40

49

54 54
43

58
45

D UT AR RI AU BI EL EL LU
G
B EP RI AM MS AB KU UN
NA M
U
P
M
J
K
B G M
S SU
SU
N A
L
BE

R K I G I Y IM
N
TE ABA D EN D AT
N
T
J
J
JA
BA

eclampsia

see relatively few normal deliveries (Table 7 and Figure 12).


The rate of c-sections among all hospital deliveries, ranging from 11% to 81%, has to be considered that can be high given the high rate of complicated deliveries in hospitals. A more accurate
analysis at the cause of c-section is very important and urgent. Nearly three-quarters (24) of all
provinces report c-section rates above 20%.
The rate of hospital delivery among all reported pregnancies is very low (Table 8). It ranges from
as low as 1% (Aceh, North Sumatra) to just over 13%.(North Sulawesi, Gorontalo, Jakarta). Twothirds (22) of all provinces fall between 2% and 6%. The rate of c-sections provided among all
deliveries is even lower, ranging from 0.3% to 7% in Jakarta. Only six provinces reported a rate
over 2% (see Figure 13).
This low rate of c-sections suggests extremely poor access to appropriate medical care and surgical intervention if required. Internationally, from 5-15% are expected to require delivery by c-sec-

45

47 50

29

23

bleeding

22

54

53

50

R
G IM EL
BA E N LT LS
L
T
A A
KA KAL K K

infection

L
T G
R O
A
LU EN LSE LTR LBA TAL
U
T
U
S
L S
SU SU ON
SU
R
O
G

LI TB TT
N
BA N

U UT
A
R
UK AL APU ABA
L
J
A
M P R
M
I

unk / other

tion for optimal maternal/neonatal outcome. In provinces where c-section rates are relatively high
(Bali, Jakarta), it is likely that some of those c-sections were not medically necessary. However,
the far larger problem is the predominance of women who require surgical delivery but are not
accessing it. With an estimated 5.1 million deliveries per year in Indonesia, at least 250,000 csections (5%) would be medically necessary to save the mother or neonate, yet only 71,000 were
reported in 2004.
The IDHS estimated that 4.1% of all deliveries were by c-section in 2002/3. If this is true, then the
number of women treated in hospital, and the number of c-sections performed is significantly under-reported in the hospital database. These are critically important indicators that help provinces
and the Ministry of Health monitor the progress of safe motherhood initiatives. Ensuring complete
hospital data on these key indicators will provide a far clearer picture of progress, or lack thereof,
toward making pregnancy safer in Indonesia.
Case fatality rates (CFR) as reported by hospitals range from zero to just over 5% (WHO > 1%).

Provincial Reproductive Health & MPS Profile of Indonesia

INTRODUCTION
Figure 12. Hospital c-section rate (%) among all hospital deliveries,
and % of hospital deliveries classified as complicated (bleeding, eclampsia, infection, other)
100
90
80
70
60
50
40
30
20
10

c-section rate in hosp

AL
U
M KU
AL
PA UT
IR PU
JA A
BA
R

LI
N
TB
N
TT

BA

S
SU UL
LT UT
E
SU NG
LS
SU E
LT L
G SU RA
O
R LB
O AR
N
TA
LO

KA
KA LBA
LT R
E
KA NG
LT
KA IM
LS
EL

0
N
SU AD
SU MU
M T
BA
KE R
PR
R I
IA
JA U
SU MB
M I
SE
BE BA L
N BE
G L
LA KU
M LU
PU
N
G
BA
N
TE
JA N
BA
R
JA DK
TE I
N
G
D
IY
JA
TI
M

Table 7. Proportion of all hospital deliveries classified as complicated, and c-section rate among hospital deliveries.
% complicated
% delivery by c-section
(among hospital obstetric cases)
(among hospital deliveries)
Maluku
8
Papua
11
Maluku Utara
8
Irian Jaya Barat
11
Papua
25
Maluku
12
Nusa Tenggara Timur
28
Maluku Utara
12
D.I Yogyakarta
33
Sumatera Selatan
14
Sumatera Utara
34
Sulawesi Tenggara
16
DKI
36
Nusa Tenggara Timur
16
Kalimantan Barat
41
Bengkulu
17
Sulawesi Utara
41
Bangka Belitung
19
Gorontalo
41
Kepri
21
Bangka Belitung
42
Riau
21
Kalimantan Timur
42
Sulawesi Utara
23
Nanggroe Aceh Darus45
Gorontalo
23
salam
Bali
47
Kalimantan Barat
24
Sumatera Selatan
47
Nusa Tenggara Barat
25
Kepri
47
Kalimantan Timur
28
Riau
47
Jawa Tengah
31
Jawa Timur
49
Lampung
32
Lampung
50
D.I Yogyakarta
32
Sulawesi Tenggara
50
Sulawesi Selatan
32
Jawa Barat
52
Sulawesi Barat
32
Sulawesi Selatan
53
Sumatera Barat
33
Sulawesi Barat
53
Kalimantan Tengah
33
Sumatera Barat
55
Sulawesi Tengah
36
Sulawesi Tengah
56
Jawa Barat
38
Jawa Tengah
56
Jawa Timur
38
Kalimantan Tengah
57
Banten
39
Nanggroe Aceh DarusBanten
58
44
salam
Kalimantan Selatan
58
Kalimantan Selatan
45
Bengkulu
62
Bali
47
Nusa Tenggara Barat
64
DKI
52
Jambi
74
Jambi
54
Irian Jaya Barat
89
Sumatera Utara
81

% complicated deliveries

WHO indicate that CFR should be > 1% to indicate good quality of care). The majority of provinces report rates in the moderate range (<2%; see Table 9 and Figure 14). Provinces with relatively
high CFRs should investigate individual hospital reports to identify which hospitals have reported
relatively high rates. This could point to a genuine problem at certain hospitals, but it could also
mean that some hospitals have better data review resulting in more complete or accurate reporting. High CFRs also could reflect a community access problem. If many women with obstetric
emergencies are unable to access the hospital quickly enough, hospital providers may have little
time or hope to save those women.
Provincial Reproductive Health & MPS Profile of Indonesia

23

INTRODUCTION

14.0

Figure 13. Rate (%) of hospital delivery among all pregnant women, and rate (%) of c-sections
among all deliveries, by province (2004 hospital report, 2004 reported pregnancies and
deliveries)

12.0

10.0

8.0

6.0

4.0

2.0

% pregnant women delivering at hospital

24

% of all deliveries by c-section

Provincial Reproductive Health & MPS Profile of Indonesia

M
AL
U
K
M U
AL
U
PA T
PU
IR
JA A
BA
R

BA
LI
N
TB
N
TT

SU
SU LU
LT T
E
SU NG
LS
SU EL
LT
R
G SU A
O
R LBA
O
NT R
AL
O

KA
L
KA BA
LT R
EN
KA G
LT
KA IM
LS
EL

TE
JA N
BA
R
D
JA K
TE I
N
G
D
I
JA Y
TI
M

BA
N

N
A
SU D
M
SU U
M T
BA
KE R
PR
I
R
IA
U
JA
SU MB
M I
SE
L
B
BE AB
N
EL
G
LA KU
M LU
PU
N
G

0.0

INTRODUCTION
Table 8. Overall rates of hospital delivery, and delivery by c-section among all reported
pregnancies or deliveries through the HIS (2004)
% hospital delivery
% delivery by c-section
(among reported pregnancies)
(among reported deliveries)
Poor coverage (less than 2%)
Poor coverage (less than 1%)
Nanggroe Aceh Darussalam

1.0

Sumatera Utara
1.1
Kalimantan Selatan
1.4
Jambi
1.6
Kalimantan Tengah
1.8
Moderate coverage (2-6%)
Lampung
2.0
Sulawesi Tenggara
2.1
Sulawesi Selatan
2.3
Sulawesi Barat
2.3
Jawa Barat
2.7
Nusa Tenggara Barat
2.9
Bangka Belitung
3.0
Banten
3.0
Sumatera Barat
3.5
Bengkulu
3.8
Sumatera Selatan
3.9
Jawa Timur
3.9
Kepri
4.3
Riau
4.3
Jawa Tengah
4.6
Nusa Tenggara Timur
4.6
Sulawesi Tengah
4.7
Maluku
4.9
Maluku Utara
4.9
Kalimantan Barat
5.2
Papua
6.0
Irian Jaya Barat
6.0
Best ranking coverage (7% or higher)
D.I Yogyakarta
7.4
Kalimantan Timur
7.9
Bali
12.3
Sulawesi Utara
13.2
Gorontalo
13.2
DKI
13.3

Sulawesi Tenggara

0.3

Nanggroe Aceh Darussalam


0.5
Sumatera Selatan
0.6
Bangka Belitung
0.6
Kalimantan Tengah
0.6
Maluku
0.6
Maluku Utara
0.6
Bengkulu
0.7
Lampung
0.7
Kalimantan Selatan
0.7
Papua
0.7
Irian Jaya Barat
0.7
Sulawesi Selatan
0.8
Sulawesi Barat
0.8
Nusa Tenggara Barat
0.8
Nusa Tenggara Timur
0.8
Sumatera Utara
0.9
Jambi
0.9
Moderate coverage (1-2%)
Kepri
1.0
Riau
1.0
Jawa Barat
1.1
Sumatera Barat
1.2
Banten
1.2
Kalimantan Barat
1.3
Jawa Tengah
1.6
Jawa Timur
1.7
Sulawesi Tengah
1.8
Best ranking coverage (2% or higher)
Kalimantan Timur
2.3
D.I Yogyakarta
2.5
Sulawesi Utara
3.2
Gorontalo
3.2
Bali
6.0
DKI
7.2

Provincial Reproductive Health & MPS Profile of Indonesia

Table 9. Case fatality rate (%) among all maternal


complications treated in hospital (2004)
Lowest ranking provinces
(2% CFR or higher)
Bengkulu
5.2
Sumatera Utara
3.5
Kalimantan Selatan
2.5
Maluku
2.4
Maluku Utara
2.4
DKI
2.3
Jawa Tengah
2.0
Moderate provinces (<2% CFR)
D.I Yogyakarta
1.9
Banten
1.3
Jawa Timur
1.2
Nanggroe Aceh Darussalam
1.0
Jambi
1.0
Sulawesi Tengah
1.0
Kalimantan Tengah
0.9
Sulawesi Tenggara
0.9
Sumatera Selatan
0.5
Sulawesi Barat
0.5
Nusa Tenggara Barat
0.5
Jawa Barat
0.4
Kalimantan Barat
0.4
Sulawesi Utara
0.4
Sulawesi Selatan
0.4
Gorontalo
0.4
Bali
0.4
Kepri
0.3
Riau
0.3
Lampung
0.3
Kalimantan Timur
0.3
Sumatera Barat
0.2
Papua
0.1
Irian Jaya Barat
0.1
Bangka Belitung
0.0
Non reporting province
Nusa Tenggara Timur
--

25

INTRODUCTION
Figure 14. Case fatality rate (%) of all complicated deliveries at hospital (2004 hospital report)

JABAR population on Lamp3 not equal to Lamp 5 in several districts,


and one obvious data entry error was detected. Error corrected, then used Lamp3 values where they were different
from Lamp5.

6.0

5.2

5.0

JAMBI, BANTEN, KALTENG, SULTENG, NTT population on Lamp3


not equal to Lamp 5 in several districts; used Lamp3 values where different.

4.0

PAPUA only 10 of 20 districts reported pop. Looked up total population of Papua + IRJABAR (2,646,489; BPS 2005), subtracted reported pop from IRJABAR (only in Lamp3), and used
remaining (1,847,695) as pop for Papua. This provides the
most accurate estimate of total population in Papua, but
cannot be broken down by district.

3.5
3.0
2.5

2.42.4

2.3
2.0

2.0
1.3

0.5

0.3

0.4

0.4

0.3

0.4

0.9
0.4

0.5

0.4

0.5
0.10.1

Data are submitted on 5 spreadsheets, Lampiran 1-5. Total populations reported in both lamp 3
and lamp5. Pregnancies are reported on Lamp1 and Lamp2. Where the same data appear on
two different Lampiran sheets, discrepancies did occur in some districts/rovinces.

Total population from Lamp3 was synchronized with Lamp5:


SUMBAR only population reported from 2001-2005 was in 2003. Therefore, population
was taken from the BPS website for that province.
SUMSEL population on Lamp3 not equal to Lamp 5 due to an obvious data entry error
corrected.

M
AL
U
M KU
AL
PA UT
I R PU
JA A
BA
R

0.0

Specific Methodology Notes and Data Cleaning / Corrections

26

0.4

BA
LI
N
TB
N
TT

0.2

1.0

0.9

N
SU AD
SU M U
M T
BA
KE R
PR
R I
IA
JA U
SU MB
M I
SE
B
BE A L
N BE
G L
LA KU
M LU
PU
N
G
BA
N
TE
JA N
BA
R
JA DK
TE I
N
G
D
I
JA Y
TI
M
KA
KA LBA
LT R
E
KA N G
LT
KA IM
LS
EL

0.0

1.2

1.0

0.30.3

Reported pregnancies, deliveries and live births


(bayi)

S
SU UL
LT UT
E
SU NG
L
SU SE
LT L
G SU R A
O
R LB
O A
N R
TA
LO

1.0

1.0

1.9

1. Synchronization of Lamp1 bumil with Lamp2 bumil, by district.


Where values different, determined which was more reasonable based on:
Bulin < bumil
Bayi < bulin
2. Ensured that all provincial totals (for all events and services) were
summed by formula. Many provinces had entered actual numbers, which
may or may not have been accurate total sums. Double-checked rowrange of formulas and corrected some errors.

3. Other minor data adjustment decisions were made. These are described
in respective profiles.

Indicator calculation
1. Indicators were calculated for each district. Coverage was then evaluated by district for
data validity. Coverage reported at very high rates (over 110% usually) or very low rates
(<20% usually) were excluded from numerator and denominators for a corrected estimate
of coverage. There were some exceptions to this rule, which are described in individual
profiles when applicable,
2. It was not uncommon that some districts did not report specific indicators. Denominators
were adjusted for these missing districts. When a substantial proportion of districts were
missing data, limiting generalizability of that indicator calculation, this was noted in the
profile.

Provincial Reproductive Health & MPS Profile of Indonesia

INTRODUCTION
Acronyms / Abbreviations
ANC
APN
BEONC
BKKBN

Antenatal Care
Basic Delivery Care (Bahasa: Asuhan Pelatihan Normal)
Basic Emergency Obstetric and Neonatal Care
Badan Koordinasi Keluarga Berencana Nasional (National Family Planning Coordinating Board)
CFR
Case Fatality Rate (deaths / obstetric complications)
C-section c/s Caesarean section
DEPKES
Departemen Kesehatan (Ministry of Health, Indonesia)
HIS
Health Information System
IBI
Ikatan Bidan Indonesia (Indonesia Midwives Assocation)
IDHS/DHS
Indonesian Demographic Health Survey
IDR
Indonesian Rupiah
K1, K4
I and IV Antenatal Visit
KN1, KN2
I and II Post Partum - Neonatal Visit
MMR
Maternal Mortality Ratio (maternal deaths / 100,000 live births)
MOH
Ministry of Health, Indonesia (Department of Health)
MPS
Making Pregnancy Safer national program/plan
PGDON
Life Saving Skill (LSS)
Polindes
Pos Bersalin Desa (village birthing post)
PONED
Pelayanan Obstetric Neonatal Emergency Dasar (Basic Emergency Obstetric
and Neonatal Care/BEONC)
PONEK
Pelayanan Obstetric Neonatal Emergency Komprehensif (Comprehensive
Emergency Obstetric and Neonatal Care/CEONC)
Posyandu
Pos Pelayanan Terpadu (integrated health post)
Puskesmas
Pusat Kesehatan Masyarakat (community health center)
SBA
Skilled birth attendant
SSM
Local Area Monitoring (Bahasa: Pemantauan Wilayah Setempat)
STI
Sexually transmitted disease
TB
Tuberculosis
TBA
Traditional Birth Attendant (dukun)
UNICEF
United Nations Childrens Fund
UNFPA
United Nations Regulation Fund
USAID
US Agency for International Development
WHO
World Health Organization

BABEL
BENGKULU
LAMPUNG

Bangka Belitung
Bengkulu
Lampung

DKI
JABAR
JATENG

Dearah Khusus Ibukota (Jakarta)


West Java (Jawa Barat)
Central Java (Jawa Tengah)

DIY

Dearah Istimewah Yogyakarta (Yogyakarta)

KALBAR
KALTENG
KALTIM
KALSEL

West Kalimantan (Kalimantan Barat)


Central Kalimantan (Kalimantan Tengah)
East Kalimantan (Kalimantan Timur)
South Kalimantan (Kalimantan Selatan)

SULUT
SULTENG
SULSEL
SULTRA
SULBAR
GORONTALO

North Sulawesi (Sulawesi Utara)


Central Sulawesi (Sulawesi Tengah)
South Sulawesi (Sulawesi Selatan)
Southeast Sulawesi (Sulawesi Tengarra)
West Sulawesi (Sulawesi Barat)
Gorontalo

BALI
NTB
NTT

Bali
West Nusa Tenggara (Nusa Tenggara Barat)
East Nusa Tenggara (Nusa Tenggara Timur)

MALUKU
MALUT
IRJABAR
PAPUA

Maluku
North Maluku (Maluku Utara)
West Papua / West Irian Jaya (Papua Barat / Irian Jaya Barat)
Papua

JATIM
BANTEN

East Java (Jawa TImur)


Banten

Provinces
NAD

SUMUT

Nanggroe Aceh Darussalam (Aceh)

North Sumatra (Sumatera Utara)

SUMBAR West Sumatra (Sumatera Barat)

KEPRI
RIAU
JAMBI
SUMSEL

Kepulauan Riau (Riau Islands)


Riau
Jambi
South Sumatra (Sumatera Selatan)
Provincial Reproductive Health & MPS Profile of Indonesia

27

28

Provincial Reproductive Health & MPS Profile of Indonesia

Nanggroe Aceh
Darussalam (NAD)

anggroe Aceh Darussalam, hereafter referred


GEOGRAPHY
to as Aceh, was the closest point of land to the
Total land area (km2)
56,500
epicenter of the massive Indian Ocean earthNumber of districts
21
quake in December 2004, which triggered
a tsunami that devastated much of the western coast
Kabupaten (regencies)
17
of the province, including part of the capital of Banda
Kota (municipalities)
4
Aceh. From 130,000 - 238,000 persons were dead or
Kecamatan (sub-districts)
243
missing, with a further 500,000 plus being made homeKelurahan/Desa (villages)
6378
less. The tsunami reached 3-5 kilometers inland along
Source: Beberapa Indikator Penting Sosialmuch of the coast. The scale of destruction, and subEkonomi Indonesia, Edisi Juli 2006, BPS.
sequent relief efforts to rebuild the infrastructure and
economy led to a peace agreement between the government of Indonesia and the Free Aceh
SOCIAL DEMOGRAPHY

NAD

National

4,271,596

220,659,431

Percent urban population (2005) 2

29

48

Percent poor population (2004)

29

17

94

87

78

116

Life expectancy at birth (2002) 2

Male: 66
Female: 70

Male: 64
Female: 68

Annual growth rate (2000-2005) 2

0.55

1.34

Total population (2005) 1


2

Adult female literacy rate (2004)

Population density (km sq.; 2005) 2

Women of reproductive age

1,001,260

51,732,453 4

Total fertility rate / 1000 women

2.4 2

2.6 6

Crude birth rate / 1000 pop. (2000) 5

22.8

22.0

Percentage of women 15-49 who have ever used contraception 2

57.5

74.1

Modern contraceptive prevalence (%) 6

No DHS

56.7

Unmet need for contraception (%) 6

No DHS

8.6

From provincial health data reports.


2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

Movement (GAM).
Because of the total disruption of routine health services and reporting in 2005 following the destruction of the capital city and more, the health information system dataset for 2005 was understandably not updated. Therefore, most health indicators are calculated using 2004 data.
The total population of Aceh in 2004 was 4.3 million, accounting for 9% of the population and
Sumatra, and nearly 2% of the total population of Indonesia. Aceh is divided into 21 districts (17
kabupaten + 4 kota [cities]) with a total of 6378 villages. The capital is Banda Aceh.
Aceh has a far lower urban population (29%) and higher poor population (29%) compared to the
national average. Adult female literacy is higher than the national rate at 94%.
The total fertility rate (2.4) and crude birth rate (22.8) are similar to the national average. The
modern contraceptive prevalence rate is not estimated as the IDHS was not conducted there.
However, the percentage of women 15-48 who have ever used contraception (58%) is lower than
the national average (74%).

Health Facilities
Aceh reports 27 hospitals, 17 public and 10 private (three districts did not report). There are 27
specialists in Ob/Gyn and 20 in pediatrics, all based at public hospitals.
Only 18 hospitals (all public) are certified in Comprehensive Emergency Obstetric and Neonatal
Care (CEONC). About half of all districts (11 of 21) report at least one CEONC hospital, and B.
Aceh reports having 6 (though some may have been destroyed in the tsunami). Districts with
no CEONC coverage are: Aceh Besar, Simeulu, Singkil, Kota Lokseumawe, Gayo Lues, Abdiya, Aceh Jaya, Nagan Raya and Bener Meriah. Some private hospitals may have CEONC
certification, but there are no data reported from private hospitals on this indicator.
Aceh reports 256 puskesmas (primary health centers) with 229 puskesmas-based general practitioners. However, only one-third (32%) of puskesmas have beds for in-patient care. The population covered by each puskesmas, on average, meets the recommended standard.

Provincial Reproductive Health & MPS Profile of Indonesia

29

NAD
HEALTH FACILITIES

2005
Public

Indonesia minimum
standard

Private

Coverage

Rows bordered in red are below minimum standard


Total hospitals (general)

17 2

10

-1 CEONC hospital /
district

3 / 500,000 pop.

Hospitals with CEONC 1

18 3

Not reported

In-hospital OBGYN

27

--

1 / 4340 pregnant women

In-hospital pediatricians

20

--

1 / 5374 newborn

Puskesmas
(primary health centers)

256

One PHC / 30,000 pop. 1 / 16,686 pop.

General practitioner in
Puskesmas

229

--

1/ 18,653 pop.

Puskesmas with bed

83

--

32% of all puskesmas

(WHO minimum standard:


one / 500,000 pop.)

4 / district
Puskesmas BEONC

34

(WHO minimum standard:


One / 125,000 pop.)

<1 / district
2 / 500,000 pop.

13% of all puskesmas


Average 1.6/district; 1 district has none (Simeulu)
1 / 125,635 pop.

Comprehensive Emergency Obsetric and Neonatal Care, 24 hour service.


2
Three districts (Abdiya, A. Jaya, B. Meriah) did not report this indicator.
3
One district (Kt Loksmw) did not report. this indicator
1

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 13% of all puskesmas report having received training and certification in Basic Emergency
Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO) recommended standard for BEONC facilities is 1 for every 125,000 people. Indonesia has adopted this
indicator, but translated it to mean at least four BEONC facilities for each district.
There is an average of 1-2 BEONC facilities per district, but the distribution of them is not adequate. One district has none (Simeulu), and several districts report only one or two, despite
significant population size (Banda Aceh, Pidie, Aceh Utara, Aceh Timur, Tamiang).
On average, the population coverage of BEONC facilities in Aceh just meets the standard of
1/125,000. However, an additional 52 BEONC facilities would be needed to reach 4 per district;
and an additional 13 to meet the recommended standard of 1/125,000 population taking into account the distribution of BEONC centers and population coverage within districts.
One immediate step would be to upgrade each puskesmas with a bed to BEONC level, focusing

30

first on districts with no BEONC or CEONC facility (see those highlighted above). The cost per
puskesmas team (3 persons) to be trained in BEONC is IDR 9.3 million (3.1 per person).

Health Personnel
There is one Ob/Gyn for every 158,000 and one pediatrician for every 214,000 people. The
coverage of GPs could not be calculated because only 6 of 20 districts reported this indicator.
Population coverage of midwives meets the recommended standard of 1/3000. However, only
6% of all villages are reported to have a midwife living in the village, with significant decreases
since 2001 (two districts did not report this indicator; the significant decline suggest an error in
data reporting). Only 11% of all midwives have received APN training and none are reported to
have received LSS training.
HEALTH PERSONNEL

(minimum standard)

2001

2005

% Change

Coverage

Rows bordered in red are below minimum standard


OB/GYNs

19

27

42%

Pediatricians

19

20

5%

Primary health center general practitioners


(One GP / 30,000 pop.)

218

135 1

Not calculated 6

Nurses trained in ANC

86

181 2

Not calculated 6

Total midwives
(One / 3000 pop.)

4743

5478

15%

1 / 780 population

Midwives living in the village


(One / village)

4254

408 3

90%

6% of villages have
village midwife

Midwives with a kit

4506

3382 4

25%

1 / 1263 population

Midwives trained in APN

NR

628

--

11% of midwives

Midwives trained in LSS

NR

55

--

Not calculated 6

Total TBA

2402

665 2

Not calculated 6

Trained TBA

1424

519 2

Not calculated 6

Not calculated 6

TBA with kit

623

285 2

Not calculated 6

Not calculated 6

Not calculated 6

Only 6 districts reported these data (Pidie, A. Utara, A. Tengah, A. Timur, Kt Loksmw, Gayo Lues).
Only 5 of 21 districts reported these data (A. Utara, A Tengah, A Timur, Kt Loksmw, Gayo Lues).
3
Two districts (Singkil and B. Meriah) did not report.
4
Two districts (Singkil and Nagan Raya) did not report.
5
Only one district reported these data (A. Utara).
6
Not calculated change due to under-reporting in 2005.
1
2

Primary Health Care Indicators


The data reported in 2005 for pregnancies, deliveries, newborn, service indicators and mortality
are identical to the 2004 dataset. This lack of updated data for 2005 is likely due to the chaos
and/or lost data following after the tsunami in December 2004. Therefore, this summary is written

Provincial Reproductive Health & MPS Profile of Indonesia

NAD
DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported
/ estimated 1

Reported pregnancies

117,177

2.74% of total population\

108.4

Reported deliveries

112,212

95.8% of reported pregnancies

109.7

Reported newborn

107,473

95.8% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.
A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.
Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.
Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

under the assumption that the most recently available data is from 2004.
The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in Aceh of 22.8 (BPS, 2000), the reported pregnancies are about 8%
higher than the estimated pregnancies, and reported deliveries are 10% higher than estimated
deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries is valid and
consistent with the country overall, further supporting the accuracy of the reported events. The
likely explanation for the discrepancy between reported and estimated events is that the crude
birth rate may be higher than 22.8, or the population may be higher than estimated.

Antenatal Care Coverage


Among reported pregnancies, 81% of the women attended at least one antenatal visit (ANC1).
This drops to 72% coverage of 4 total antenatal visits (ANC4), which is below the 2007 target
of 84%. Over 23,000 pregnant women never accessed any antenatal care, and nearly 10,000
women who have accessed antenatal care once do not obtain the minimum standard of 4 antenatal visits. These women are either not adhering to the recommended antenatal schedule or are
accessing ANC too late to reach 4 visits. Quality of care, community awareness, and logistical
accessibility factors likely account for these missed opportunities.
There is some variation in reported antenatal coverage by districts.
Five districts reported lower than
average rates of ANC1 and ANC4
attendance, respectively: Aceh
Timur (59% and 50%), Aceh
Tenggara (57% and 52%), Aceh
Selatan (73% and 48%), Aceh
Jaya (65% and 51%), and Nagan Raya (48% and 57%).

Antenatal Care Coverage 2004

Skilled Birth Attendance


Only 58% of all reported deliveries are
attended by a skilled health professional
(SBA=skilled birth attendant). This leaves
over 65,000 women delivering without any
skilled birth attendant. The national target
for skilled birth attendance is 82% by 2007
and 90% by 2010.

Skilled Birth Attendant Coverage


2004
no SBA
42%

SBA
58%

Four districts, Aceh Tenggara (44%),


Aceh Selatan (46%), Aceh Jaya (44%)
and Nagan Raya (40%), report lower
skilled birth attendant coverage rates compared to the provincial average.

Postpartum (Neonatal) Care Coverage


The proportion of newborn who attend
the first neonatal visit (KN1) was not reported in 2002-5, but only 54% attended
KN2. The latest available data on KN1
was from 2001 which showed 73% attendance, but KN2 was not reported in that
year. Despite the missing data, it appears
than Aceh is well below targets for postpartum/neonatal care coverage.

Postpartum / Neonatal Care


Coverage 2004 (KN1 not reported)
KN1 &
KN2, 54%

KN1 only
or no
postnatal /
neonatal
care, 46%

Two districts, Aceh Jaya (21%) and Nagan Raya (34%), report lower KN2 coverage rates compared to the provincial average.

Risk Detection and Management of Complications

ANC1 & 4
73%
no ANC
19%

ANC1 only
8%

In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate of
pregnant women detected as at risk by the community, including cadres, TBAs or other lay persons
(i.e. non-health professionals). National cutting point for complication in pregnancy stated that 20%
of all pregnant women will experience some complication of pregnancy, including a recognizable risk
factor for poor maternal or fetal outcome. Therefore over 24,000 pregnant women are expected to be
at risk in Aceh annually (20% of all pregnant women reported).

Provincial Reproductive Health & MPS Profile of Indonesia

31

NAD
Overall, less than 6% of
these high risk women
were detected as being at risk by community
members. However, a
very high level of pregnant women were detected at risk by a health
provider. While a maximum of about 20% of
all pregnant women are
expected to need risk detection, Aceh detected
nearly twice this amount, or over 30% of all pregnant women (156% of those expected to be at
risk). This finding is hard to interpret. It is possible that the definition and reporting of this indicator is inaccurate.

Maternal and Neonatal Deaths


There were 117 maternal deaths reported in Aceh in 2004 (from 15 of 20 districts only; no new data
for 2005 reported). The maternal mortality ratio (MMR) was estimated to be 109. This is smaller
than national estimates (MMR=230,
range 58 to 440, WHO/UNICEF/UNFCauses of Maternal Deaths, 2004
PA, 2000 or MMR=307, IDHS, 2002/3),
but is likely to be under-reported given
infection
eclampsia
the low rate of skilled birth attendance
16%
12%
other /
unknown
and incomplete reporting from all dis20%
bleeding
tricts.
52%

32

The number of reported stillbirths and neonatal deaths indicate serious under-reporting. Based on
reported data, Aceh has a neonatal mortality rate of only 3.7 compared to a national estimate of 18
neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the Aceh data on neonatal
mortality are accurate enough to utilize as an outcome indicator.
The ratio of early to late neonatal deaths is not consistent with international estimates, with less than
half (48%) of all reported neonatal deaths occurring before the first 7 days. This means that early
neonatal deaths are more often missed than late neonatal deaths, though all neonatal deaths appear
to be under-reported. WHO estimates that three-quarters of all neonatal deaths in Indonesia occur in
the first week of life, suggesting the importance of improving quality and access to pregnancy care,
safer delivery and emergency neonatal care (e.g. resuscitation, infection prevention, early detection
and treatment, and management of low birth weight).
The reported stillbirth rate is 2.4 in ACEH compared to the national estimate of 17.

Hospital Management of Maternal and Neonatal Complications

There is no data reported on management of complications, maternal or neonatal.

The predominant cause of maternal


death in Aceh is bleeding, followed
by infection and eclampsia. Key interventions to reduce risk of hemorrhage
should be emphasized (iron deficiency
anemia control, trained midwives, appropriate use of oxytocics, access to
safe blood transfusion/fluid replacement). Women with signs or symptoms
of hypertensive disorders of pregnancy
should be strenuously referred to specialist care at a tertiary hospital, since
early delivery by c-section is the most
effective measure to prevent progres-

sion to eclampsia and death.

HOSPITAL CASES

% of
Number Hospital
Cases

% Coverage
(reported pregnancies) 1

OB/GYN cases treated at hospital (includes


normal deliveries)

1143

--

Complicated OB/GYN cases treated at hospital 2

514

45.0

--

1.0

4.3% of reported maternal


deaths (115 in 2004) occured
in hospital

Hospital admissions due to abortion

224

19.6

--

Caesarean sections

501

43.9

0.5% of all deliveries

Case fatality rate 3

1.0% of all pregnancies

Denominators from 2004 data were pregnancies: 117,177; deliveries: 112,212.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Maternal Mortality Ratio 2001-04


(deaths / 100,000 reported newborn)
250
200
150

Reported data from hospitals in Aceh indicate that only about 1% of all deliveries
occur in hospital. Nearly half (45%) of
these hospital deliveries are classified as
complicated.

(no death data available for 2005)

214
156
110

100

109

50
0
2001

2002

2003

2004

2005

The case fatality rate for complications


among hospital deliveries is moderate at
1.0%, but only 4% of all reported maternal

Provincial Reproductive Health & MPS Profile of Indonesia

NAD
deaths occurred in the hospital.
Nearly 20% of all hospital admissions are due to abortion, indicating a high rate of unsafe abortion practices in ACEH. 44% of all deliveries in hospital are by caesarean section. This high c/s
rate should be further analyze to understand the implication of it. Indeed, the c-section rate over
all deliveries in the province, both reported and estimated, is very low (0.5%) and suggests that
there are many women delivering outside of hospitals who would have had better outcomes if
delivered by c-section.

5. Improve community detection of women at risk.

Coverage of health personnel and service inputs


1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
BEONC UNMET NEED ACCORDING TO STANDARDS
Total UnTotal
#
met Need Pop. /
District
popula- BEONC
(MOH: 4/ BEONC
tion
in 2005
district)
28,657
264,097
306,716
519,417
495,380
187,824
316,535
169,409
198,257
190,638
78,126
147,018
350,611
168,404
136,382
69,146
118,259
80,541
114,521
232,174
99,484
4,271,596

3. Increase the number of midwives who have received APN and BEONC training, particularly
in districts reporting none. Ensure that every puskesmas has at least one trained ANC
midwife.
4. Increase the number of women who deliver with a skilled birth attendant, and the proportion
of newborn and postpartum mothers who receive postnatal care.

Recommendations

1 Sabang
2 B.Aceh
3 A.Besar
4 Pidie
5 A.Utara
6 A.Tengah
7 A.Timur
8 A.Tenggara
9 A.Barat
10 A.Selatan
11 Simeulu
12 Singkil
13 Bireun
14 Kt.Loksmw
15 Kt.Langsa
16 Gayo Lues
17 Abdiya
18 A.Jaya
19 Nagan Raya
20 Tamiang
21 B.Meriah
TOTAL

2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution across all districts, and correlation with population size, are taken
into account in the scale-up plan.

1
1
6
2
2
1
1
1
2
1
0
2
3
1
1
1
1
2
2
1
2
34

3
3
0
2
2
3
3
3
2
3
4
2
1
3
3
3
3
2
2
3
2
52

28,657
264,097
51,119
259,708
247,690
187,824
316,535
169,409
99,128
190,638
-73,509
116,870
168,404
136,382
69,146
118,259
40,270
57,260
232,174
49,742
125,635

WHO
recommended coverage
(1 / 125,000)
1
2
3
4
4
2
3
2
2
2
1
2
3
2
1
1
1
1
1
2
1
41

6. Initiate or strengthen Maternal and Neonatal Motrality audit at district and health facilities
level.

Data quality and reporting


7. Invest in re-training and re-invigorating health officials at all levels on improving the quality

Unmet
need
(WHO)
0
1
0
2
2
1
2
1
0
1
1
0
0
1
0
0
0
0
0
1
0
13

COVERAGE OF MIDWIFE PERSONNEL


Total reported deDistrict
liveries
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

Sabang
B.Aceh
A.Besar
Pidie
A.Utara
A.Tengah
A.Timur
A.Tenggara
A.Barat
A.Selatan
Simeulu
Singkil
Bireun
Kt.Loksmw
Kt.Langsa
Gayo Lues
Abdiya
A.Jaya
Nagan Raya
Tamiang
B.Meriah

TOTAL

Provincial Reproductive Health & MPS Profile of Indonesia

771
6,167
8,032
13,158
12,694
6,977
11,943
4,475
4,035
5,190
1,828
3,481
9,317
4,396
3,370
1,970
3,005
2,249
3,343
5,811
0

112,212

Total APN midwives

4
76
174
96
7
4
4
4
131
14
20
9
26
8
4
5
4
22
6
4
6
628
(1 / 179 deliveries)

Total LSS midwives

--
--
--
--
5
--
--
--
--
--
--
--
--
--
--
--
--
--
--
--
--
5

33

NAD
and completeness of all health data reported. The tsunami has certainly compromised this
system, but the system was already weak before the tsunami as evidenced by lack of data
on several indicators since 2001.
8. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at
district and provincial levels to improve quality of data.
9. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for
more

KEY INDICATORS AND NATIONAL TARGETS

Aceh

National Target

2001

2004 *

ANC1 (K1)

89

81

ANC4 (K4)

75

SBA deliveries
Postpartum / Neonatal visit (KN1)
Risk detection of pregnant women by community

2007

2010

72

84

95

65

58

82

90

73

Not reported

83

90

<0.5

Obstetric complications managed

Not reported Not reported

60

80

Neonatal complications managed

Not reported Not reported

60

80

Caesarian section rate (% of hospital deliveries)

42

44

Caesarian section rate (% of reported deliveries)

1.3

0.5

Hospital OB/GYN cases as % of all pregnancies

3.2

1.0

Maternal Mortality Ratio


(maternal deaths / 100,000 estimated live births)

156

109

34

Provincial Reproductive Health & MPS Profile of Indonesia

NORTh
sUMATRA

he total population of North Sumatra is 12.1 million, accounting for over 5% of the total population in Indonesia, and 27% of the population
in Sumatra. North Sumatra is divided into 25
districts (18 kabupaten + 7 kota [cities]) with a total of
5612 villages. The capital city is Medan with over 2 million people.

GEOGRAPHY
Total land area (km2)

72,428

Number of districts

25

Kabupaten (regencies)

18

Kota (municipalities)

Kecamatan (sub-districts)

357

Kelurahan/Desa (villages)

5612

North Sumatra has a slightly lower urban population


Source: Beberapa Indikator Penting Sosial(46%) and poor population (15%), compared to the naEkonomi Indonesia, Edisi Juli 2006, BPS.
tional average. Adult female literacy is above the national rate at 95%.
The total fertility rate (3.0) and the crude birth rate (23.8) are above the national average. The
SOCIAL DEMOGRAPHY

North Sumatra

National

12,123,360

220,659,431

46

48

15

17

Adult female literacy rate (2004) 2

95

87

Population density (km sq.; 2005) 2

169

116

Life expectancy at birth (2002) 2

Male: 65
Female: 69

Male: 64
Female: 68

Annual growth rate (2000-2005) 2

1.35

1.34

Total population (2005)

Percent urban population (2005)


Percent poor population (2004)

Women of reproductive age

3,060,164

Total fertility rate / 1000 women 6

51,732,453 4

3.0

2.6

23.8

22.0

Percentage of women 15-19 who have begun childbearing 6

4.2

10.4

Modern contraceptive prevalence (%) 6

43.2

56.7

Unmet need for contraception (%) 6

13.0

8.6

Crude birth rate / 1000 pop. (2000)

From provincial health data reports.


2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
From provincial website: http://sumut.bps.go.id.
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

modern contraceptive prevalence is significantly lower (43%) than the national average, and the
percentage of young women who have begun childbearing (4%) is less than half the national
average. Among all contraceptive users, most women choose injection (30%), oral contraceptives (25%), traditional methods (18%) or tubal ligation/vasectomy (13%). The rate of using a
traditional method of contraception is more than twice as high as the estimate for all provinces in
Indonesia.

Health Facilities
North Sumatra reports 107 hospitals, two-thirds private. There are 22 Ob/Gyn and 17 pediatric
staff in public hospitals (total: 28), compared to only 14 of each type of specialists in private hospitals (total: 79). According to the National Bureau of Statistics (BPS 2005), there are in total 147
total hospitals (28 public and 119 private). This represents a 43% increase in private hospitals
since 2001, and also reflects significant under-reporting of private hospital status in the routine
health information system.
Only 15 hospitals (all public) are
certified as providers of CompreContraceptive Methods Used
(IDHS 2002/3)
hensive Emergency Obstetric and
Neonatal Care (CEONC). Ten out
injection,
of 25 districts report having no
pill, 25%
30%
CEONC hospital (Nias Selatan,
IUD, 6%
Mandailing Natal, Tapanuli Setraditional
methods,
latan, Tapanuli Tengah, Humpermanent,
18%
13%
bang Hasundatan, Toba Samisir,
Samosir, Pak-Pak Bharat, Sercondom, 3%
implant, 5%
dang Bedegai, Padang Sidimpuan). Some private hospitals
may provide CEONC service, but
there are no data reported from private hospitals on this indicator.
North Sumatra has 437 puskesmas (primary health centers), each with as many puskesmasbased general practitioners. However, only 24% of puskesmas have beds for in-patient care.
The population covered by each puskesmas, on average, meets the recommended standard.

Provincial Reproductive Health & MPS Profile of Indonesia

35

NORTH SUMATRA
Access to Basic Emergency Obstetric Care (BEONC or PONED)

Health Personnel

Only 11 puskesmas (2.5%) report having received training and certification in Basic Emergency
Obstetric and Neonatal Care (BEONC). This extremely low reported coverage rate may be due
to poor record keeping and reporting. These data are not at all consistent with 2004 data which
reported the existence of a total of 34 BEONC facilities from only 9 out of 25 districts that entered
data in 2004 on this indicator.

The data on reported health personnel is incomplete for many indicators in both 2001 and 2005,
making it difficult to identify improving or deteriorating trends in coverage over time. Specialists
appear to be significantly under-reported, and general practitioners appear to have increased
over 500% since 2001. Trained nurses in ANC and APN trained midwives were not reported in
2005.

HEALTH FACILITIES

2005
Public

Private

Indonesia minimum standard

Coverage

Rows bordered in red are below minimum standard


Total hospitals (general)

Hospitals with CEONC 1

28

79

Not reported

15

--

Total midwives appear to have increased in number since 2001 by over 50%, and the proportion of
villages covered by a midwife living in the village has reportedly increased nearly 9-fold to about 75%
of all villages in 2005. Meanwhile, the number of midwives with a safe delivery kit has reportedly
decreased over 50% since 2001. These inconsistencies in midwife coverage and training make the
overall picture of skilled and safe delivery coverage in North Sumatra very difficult to evaluate.

--

1 CEONC hospital /
district

<1 / district
(WHO minimum stan- <1 / 500,000 pop.
dard:
one / 500,000 pop.)

In-hospital OBGYN

22

14

--

1 / 9225 pregnant women

In-hospital pediatricians

17

14

--

1 / 9410 newborn

HEALTH PERSONNEL
(minimum standard)

2001

%
Change

2005

Coverage

Rows bordered in red are below minimum standard


OB/GYNs

Not reported

14 1

--

Pediatricians

102

13

87%

Primary health center general


practitioners
(One GP / 30,000 pop.)

91

576

533%

Nurses trained in ANC

3193

Not reported 2

--

1 / 21,048 population

Puskesmas
(primary health centers)

437

One PHC / 30,000


pop.

1 / 27,742 pop.

General practitioner in
Puskesmas

437

--

1/ 27,742 pop.

Total midwives
(One / 3000 pop.)

4107

6326 3

54%

1 / 1916 population

Puskesmas with bed

104

--

24% of all puskesmas

Midwives living in the village


(One / village)

430

3839 4

793%

68% of villages have


village midwife

Midwives with a kit

4000

1742

56%

1 / 6959 population

Midwives trained in APN

Not reported

Not reported

--

--

Midwives trained in LSS

Not reported

327

--

1 / 37,074 population

Total TBA

8078

Trained TBA
TBA with kit

4 / district
Puskesmas BEONC

11

2.5% of all puskesmas

Average <1/district; 12/25


(WHO minimum standistricts report none
dard:
One / 125,000 pop.)
1 / 1,102,124 pop.

Comprehensive Emergency Obsetric and Neonatal Care, 24 hour service.

The current World Health Organization (WHO) recommended standard for BEONC facilities is
1 for every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at
least four BEONC facilities for each district. Given the inconsistent and clearly under-reported
coverage in BEONC facilities, it is difficult to evaluate the adequacy of BEONC coverage in North
Sumatra.
The priority is to compile accurate data on BEONC facilities, by district, and identify the districts
most under-served by BEONC and CEONC facilities taking into account population size. The cost
per puskesmas team (3 persons) to be trained in BEONC is IDR 9.3 million (3.1 per person).

36

7673

5%

6174

5671

8%

74% of all TBA

3166

3021

5%

39% of all TBA

Two districts (Nias, Medan) did not report this indicator.


Only two districts reported this indicator (Tanapuli Tengah and Asahan).
3
There are two total columns on the data collection tool often leading to confusion. The first reports 6326 midwives,
the second reports 10,888 bidan di desa (though only 3839 tinggal di desa). Previous years data on total midwives
was more consistent with the 6326 total.
4
All seven kota reported zero midwives living in the village.
5
Only three districts reported this indicator (Deli Serdang, Medan, Binjai).
6
Four districts did not report total TBAs (Deli Serdang, Serdang Bedegai, Langkat, Tanjung Balai).
7
Five districts did not report trained TBAs or TBAs with kit (Deli Serdang, Serdang Bedegai, Langkat, Tanjung Balai,
Padang Sidimpuan).
1
2

Provincial Reproductive Health & MPS Profile of Indonesia

NORTH SUMATRA
Primary Health Care Indicators
Ratio of reported / estimated 1

DENOMINATORS FOR KEY


INDICATORS

Number

Reported pregnancies

332,087

2.74% of total population

103.7

Reported deliveries

308,416

92.9% of reported pregnancies

101.8

Reported newborn

291,723

94.6% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.
A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.
Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth rate
may be higher than estimated, the population may be higher than reported, or there is some double-counting of events.
Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth rate
may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in North Sumatra. More than 95% of women report having an abdominal
examination; only 75% report having their blood pressure measured, less than 67% report having their weight measured and only 60% received iron tablets. Just over one-quarter (26%)
report being informed of signs of pregnancy complications and only 15% report giving a blood
sample. These data show that the quality of antenatal care is low in many places, and that critical components of good antenatal care are not always provided.
There is minimal variation in reported antenatal coverage by most districts, however, two districts, Samosir and Simalungun, do show substantially lower rates of ANC1 (60% and 64%
respectively) and ANC4 (58% and 62% respectively) compared to the provincial average. Nias
Selatan has reasonable ANC1 coverage (74%), but drops to only 61% ANC4 coverage.

Skilled Birth Attendance Coverage

The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.
Assuming a crude birth rate in North Sumatra of 23.8 (BPS, 2000), the reported pregnancies are
about 4% higher than the estimated pregnancies and reported deliveries are 2% higher than estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries is valid
and consistent with the country overall, further supporting the accuracy of the reported events.
The likely explanation for the small discrepancy between reported and estimated events is that
the crude birth rate may be higher than 23.8, or the population may be higher than estimated.
Note: Reported pregnancies, deliveries and newborn in one district (Pakpak Bharat) was close
to 50% of its population. Therefore, MOH formulas were used to calculate estimated pregnancies and deliveries for this district. Estimated newborn was calculated with a multiplier (reported
deliveries x 94.4%) based on all reported deliveries and newborn in Indonesia. This district was
removed from all indicator calculations as well due to data reports inconsistent with expected
pregnancies, deliveries or newborn.

Antenatal Care Coverage


Among reported pregnancies, 84% of the women attended at least one antenatal visit (ANC1).
This drops to 80% coverage of 4 total antenatal
visits (ANC4). Over 55,000 pregnant women
never accessed any antenatal care, and nearly
12,000 women who have accessed antenatal
care once do not obtain the minimum standard
of 4 antenatal visits. These women are either
not adhering to the recommended antenatal
schedule or are accessing ANC too late to reach
4 visits. Quality of care, community awareness, and logistical accessibility factors likely account
for these missed opportunities.

Nearly three-quarters (74%) of all reported deliveries are attended by a skilled


health professional (SBA=skilled birth attendant). This leaves over 79,000 women
delivering without any skilled birth attendant. The national target for skilled birth
attendance is 82% by 2007 and 90% by
2010.
According to IDHS data, women in North
Sumatra are less likely to deliver with a
doctor, but much more likely to deliver
with a nurse/midwife compared to the Indonesian average. Only 7% are attended
by a doctor, but nearly 73% are delivered
by a nurse/midwife. Only 18% are delivered by a TBA, relative or other person.
One-third (33%) deliver at a health facility (mostly private), while the remaining
(65%) deliver at home.

Provincial Reproductive Health & MPS Profile of Indonesia

37

NORTH SUMATRA
Two districts, Nias (44%) and Nias Selatan (60%), report lower skilled birth attendant coverage
rates compared to the provincial average.
Trends in coverage of antenatal care and skilled birth attendance from 2001-05 show inconsistent increases in coverage of both indicators. Antenatal care increased by about 10 percentage
points, while SBA coverage increased by about 11% percentage points.

Postpartum (Neonatal) Care Coverage

Management of neonatal complications (estimated to be 25% of newborn born) appears to be


even lower. While the national target for 2007 is 60%, increasing to 80% in 2010, North Sumatra
reports managing less than 2% of all expected neonatal complications.

Maternal and Neonatal Deaths

The IDHS estimates that fewer than 44% of all


births are officially registered in North Sumatra
which is lower than the national estimated level
(53%). About 75% of all reported newborn attend
the first neonatal visit (KN1), but only 42% attend
the second (KN2). The IDHS found lower rates of
early postpartum/neonatal care, but similar rates
of missing care altogether (29%).

There were 135 maternal deaths reported in North


Sumatra in 2005, with an estimated maternal mortality ratio (MMR) of 46. This is far smaller than
national estimates (MMR=230, range 58 to 440,
WHO/UNICEF/UNFPA, 2000 or MMR=307, IDHS,
2002/3) and suggests serious under-reporting.

Five districts, Labuhan Batu (23%), Asahan (25%), Simalungun (17%), Langkat
(27%) and Binjai (24%), reported lower
postpartum/neonatal coverage rates compared to the provincial average. Nine districts were excluded from the calculation
of KN2 coverage due to lack of reporting
any data, under-reporting (6%) or over-reporting (108-500%) coverage.

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring
progress toward making pregnancy safer
is the rate of pregnant women detected as
at risk by the community, including cadres, TBAs or other lay persons (i.e. nonhealth professionals). Indonesia adopted
that 20% of all pregnant women will need
medical attention during pregnancy or delivery, or over 66,000 pregnant women in
North Sumatra annually (20% of all pregnant women reported).

The predominant cause of maternal death


in North Sumatra is bleeding, though
Maternal Mortality Ratio 2001-05
eclampsia plays a significant role. Key
(deaths / 100,000 reported newborn)
(no death data available for 2002)
interventions to reduce risk of hemor60
rhage should be emphasized (iron defi50
46
50
ciency anemia control, trained midwives,
35
40
30
appropriate use of oxytocics in active
30
rd
management of 3 stage as per national
20
policy, access to safe blood transfusion/
10
0
fluid replacement). Women with signs or
2001
2002
2003
2004
2005
symptoms of hypertensive disorders of
pregnancy should be treated properly and
actively referred to specialist care at a hospital, since early delivery by c-section is the most effective measure to prevent progression to eclampsia and death.
It should be noted that more than one-third (38%) of all maternal deaths are not attributed to
any immediate cause of death. More importance should be attached to correctly diagnosing
and recording causes of maternal deaths in order to more closely track progress toward effective management of obstetric complication and identify potential interventions to reduce maternal
mortality.

Overall, only 10% of this total number of women were detected as being at risk by community
members and 39% were detected by a health provider.

38

Less than 3% of all expected complications (20% of pregnancies) were managed by the health
care system at primary or tertiary levels of care. The national target for obstetric complications
management is 60% by 2007 and 80% by 2010. North Sumatra is far below national expectations
on this indicator.

The number of reported stillbirths and neonatal deaths indicate serious under-reporting. Based
on reported data, North Sumatra has a neonatal mortality rate of only 2.2 compared to a national
estimate of 18 neonatal deaths per 1000 life births (WHO, 2006). Reported neonatal mortality
rate also lower than IDHS (2002 2003) that is 24 / 1000 births and post neonatal mortality rate is
18 per 1000 life births. Therefore, it is unlikely that the North Sumatra data on neonatal mortality
are accurate enough to utilize as an outcome indicator.

Provincial Reproductive Health & MPS Profile of Indonesia

NORTH SUMATRA
The ratio of early to late neonatal deaths is consistent with international estimates, and it should
be emphasized that over 72% of neonatal deaths occurred in the first 7 days of life suggesting
the importance of improving quality and access to pregnancy care, safer delivery and emergency
neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis,
and management of low birth weight newborn).
The reported stillbirth rate is 1.6 / 1000 estimated deliveries in North Sumatra compared to the
national estimate of 17.

Hospital Management of Maternal and Neonatal Complications


Reported data from hospitals in North Sumatra indicate that about 1% of all deliveries occur in
hospital. Over one-third (34%) of these deliveries are classified as complicated.
The case fatality rate for complications among hospital deliveries is high at 3.5% and 55% of all
reported maternal deaths occurred in the hospital.

HOSPITAL CASES

Number

% of
Hospital
Cases

% Coverage
(reported pregnancies) 1

OB/GYN cases treated at hospital (includes normal deliveries)

3508

--

1.1% of all pregnancies

Complicated OB/GYN cases treated at


hospital 2

1201

34.2

--

Case fatality rate 3

42

3.5

54.5% of reported maternal


deaths (77 in 2004) occured in
hospital

Hospital admissions due to abortion

427

12.2

--

Caesarean sections

2834

80.8

0.9% of all deliveries

Denominators from 2004 data were pregnancies: 320,844; deliveries: 303,501.


Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1
2

Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care
or community preparedness in recognizing
risk and making timely referrals. The status
of maternal and neonatal mortality audits is
not reported in the HIS data, but should be
tracked closely by individual hospitals, districts and provinces and would be an important indicator to monitor nationally.
Over 12% of all hospital admissions are due to

abortion, suggesting a high rate of unsafe abortion practices in North Sumatra. Due to the high rate of
complicated cases handled in hospital, nearly 81% of all deliveries in hospital are by caesarean section. This can reflect an unnecessarily high c-section rate, however, we have to take in consideration
the very low rate of delivery in hospital overall. Indeed, the c-section rate over all deliveries in the
province is less than 1% and suggests that there are many women delivering outside of hospitals who
would have had better outcomes if delivered by c-section. Internationally, from 5-15% of women are
expected to require delivery by c-section for optimal maternal/neonatal outcome.

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
BEONC UNMET NEED ACCORDING TO STANDARDS
Total UnWHO rec#
met Need
ommended Unmet
Total popuPop. /
District
BEONC (MOH:
coverage
need
lation
BEONC
in 2005 4 / dis(1 /
(WHO)
trict)
125,000)
1 Nias
433,350
0
4
-4
4
282,715
0
4
-2
2
2 Nias Selatan
Mandailing
Natal
379,045
0
4
-3
3
3
609,922
1
3
609,922
5
4
4 Tapanuli Selatan
278,472
1
3
278,472
2
1
5 Tapanuli Tengah
255,400
1
3
255,400
2
1
6 Tapanuli Utara
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

Humbang Hasundatan
Toba Samosir
Samosir
Labuhan Batu
Asahan
Simalungun
Dairi
Pak-Pak Bharat
Karo
Deli Serdang
Serdang Bedagai
Langkat
Sibolga
Tanjung Balai
Pematang Siantar
Tebing Tinggi
Medan -- kota
Binjai

152,519

--

167,587
119,873
933,866
1,009,856
818,975
259,158
34,260
312,300
1,523,881
583,071
955,348
87,260
149,238
227,551
134,382
2,010,676

0
0
1
0
0
1
0
1
1
0
3
0
0
0
0
1

4
4
3
4
4
3
4
3
3
4
1
4
4
4
4
3

--933,866
--259,158
-312,300
1,523,881
-318,449
----2,010,676

1
1
8
8
7
2
1
3
12
5
8
1
1
2
1
16

15
2

--

89 1,102,124

99

88

232,236

25 Padang Sidimpuan

172,419

TOTAL

12,123,360

11

Provincial Reproductive Health & MPS Profile of Indonesia

--

1
7
8
7

1
2
11
5

1
1
2
1

39

NORTH SUMATRA
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Ensure minimum standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training, particularly
in districts reporting none. Ensure that every puskesmas has at least one trained ANC
midwife.
4. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they
drop out?
5. Improve management of obstetric and neonatal complication. Community awareness of
risk in pregnancy and active commitment to ensuring good referral systems could contribute significantly toward even safer deliveries.
6. Increase community awareness of the importance of delivering with a skilled birth attendant
and postnatal care to improve coverage with a skilled birth attendant and coverage of postpartum/neonatal care.
7. Conduct maternal mortality audit reviews at hospital and community (primary health care)
levels. Reduce the proportion of maternal deaths attributed to unknown or other causes.
8. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


9. Designate a data quality and completeness team to investigate all health input data both
KEY INDICATORS AND NATIONAL TARGETS

National
Target

North Sumatra
2001

2005 * 2007 2010

ANC1 (K1)

80

83

ANC4 (K4)

70

80

84

95

SBA deliveries

63

74

82

90

Postpartum / Neonatal visit (KN1)

65

75

83

90

Risk detection of pregnant women by community

49

9.9

Obstetric complications managed

Not reported

2.5

60

80

Neonatal complications managed

Not reported

1.4

60

80

Caesarian section rate (% of hospital deliveries)

51

81 *

Caesarian section rate (% of reported deliveries)

1.6

0.9 *

Hospital OB/GYN cases as % of all pregnancies

3.1

1.0 *

Maternal Mortality Ratio


(maternal deaths / 100,000 estimated live births)

50

46

COVERAGE OF MIDWIFE PERSONNEL


Total reported
District
deliveries
1 Nias
2 Nias Selatan
3 Mandailing Natal
4 Tapanuli Selatan
5 Tapanuli Tengah
6 Tapanuli Utara
7 Humbang Hasundatan
8 Toba Samosir
9 Samosir
10 Labuhan Batu
11 Asahan
12 Simalungun
13 Dairi
14 Pak-Pak Bharat
15 Karo
16 Deli Serdang
17 Serdang Bedagai
18 Langkat
19 Sibolga
20 Tanjung Balai
21 Pematang Siantar
22 Tebing Tinggi
23 Medan -- kota
24 Binjai
25 Padang Sidimpuan

TOTAL
( - : not reported )

Total LSS midwives

-
-
-
-
-
-
-
-
20
-
-
-
-
-
-
25
2

5,637

308,416

47

15

15
17
15

19

10
8
4

16

0
13
9

15
21
12

18

8
12
12

10

41
10

12
327
1 / 943 deliveries)

facility and personnel. Team members should include health personnel at district and provincial levels. They should receive special training in the HIS, and should have time and
resources to conduct site visits to facilities and communities to conduct refresher training
and data audits. Data quality team members should conduct periodic (monthly or quarterly)
internal data consistency and logical checks at district and provincial levels and report on
these checks to highlight areas that require improvement.
10. Data quality team members should pay particular attention to improving the detection and
reporting of maternal deaths, stillbirths and neonatal deaths for more accurate monitoring
of changes over time in management of pregnancy and obstetric risk. They should also
look closely at how to collect more accurate and complete data describing private hospitals
given the recent increase in the number of private hospitals.

* c-sections and hospital data from 2004.

40

11,315
7,350
9,745
16,734
7,319
7,416
3,962
4,705
3,768
23,607
25,956
19,555
7,063
856
7,237
33,874
15,226
24,030
2,089
3,496
6,551
3,546
51,317
6,062

Total APN
midwives

Provincial Reproductive Health & MPS Profile of Indonesia

WEST
sUMATRA

he total population of West Sumatra in 2005


is 4.6 million, accounting for over 2% of the
total population in Indonesia and nearly
10% of Sumatra. West Sumatra is divided
into 19 districts (12 kabupaten + 7 kota [cities]) with
a total of 901 villages. The capital is Padang.
West Sumatra has a lower urban population (34%)
and lower poor population (11%) compared to the
national average. Adult female literacy is higher
than the national rate at 94%.

GEOGRAPHY
Total land area (km2)

42,225

Number of districts

19

Kabupaten (regencies)

12

Kota (municipalities)

Kecamatan (sub-districts)

157

Kelurahan/Desa (villages)

901

Source: Beberapa Indikator Penting Sosial-Ekonomi


Indonesia, Edisi Juli 2006, BPS.

The total fertility rate (3.2) is higher than the naSOCIAL DEMOGRAPHY

West Sumatra

National

4,603,957

220,659,431

Percent urban population (2005) 2

34

48

Percent poor population (2004)

11

17

94

87

103

116

Life expectancy at birth (2002) 2

Male: 64
Female: 68

Male: 64
Female: 68

Annual growth rate (2000-2005) 2

0.71

1.34

1,086,262 3

51,732,453 4

3.2

2.6

21.8

22.0

7.9

10.4

46.2

56.7

12.3

8.6

Total population (2005) 1


2

Adult female literacy rate (2004) 2


Population density (km sq.; 2005)

Women of reproductive age


Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing
Modern contraceptive prevalence (%)
Unmet need for contraception (%)

Provincial health data report 2005 did not report population. West Sumatra population from provincial website: http://sumbar.
bps.go.id/. National population from provincial health data reports.
2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
From provincial website: http://sumbar.bps.go.id.
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3

tional average, and crude birth rate (21.8) is slightly


lower. The modern contraceptive prevalence rate
is also lower (46%) but the percentage of young
women who have begun childbearing is lower as
well (7.9%). Among all contraceptive users, most
women choose injection (42%), oral contraceptives
(17%), traditional methods (13%), IDU (12%), or
implants (9%).

Health Facilities
West Sumatra has 46 hospitals as reported on the BPS provincial website (last reported by HIS in
2003 when there were only 37 hospitals). There are 19 public and 27 private hospitals. The only
indicator in this section reported in 2005 was the total number of specialists working in hospital:
59 Ob/Gyn and 49 pediatricians.
Only 16 hospitals (all public, last reported in 2003) are certified in Comprehensive Emergency
Obstetric and Neonatal Care (CEONC). This
indicator was not reported in 2005. Among the 16
injection,
42% Pariaman, Lima Puluh Kota, Pasaman,
districts in the province in 2003, 4 districts (Padang
pill, 17%
Mentawai) did not have a CEONC facility. Some private hospitals may have CEONC certification, but there are notraditional
data reported from private hospitals on this indicator. It should be noted
that these indicators are
several years old and do not reflect the current total number of districts
methods,
in the province.
13%
West Sumatra had 205 puskesmas (primary health centers) as last reported in 2003 with almost as
many puskesmas-based general practitioners. However, only one-third (31%) of all puskesmas had
beds for in-patient care in 2003.

Access to Basic Emergency Obstetric Care (BEONC or PONED)

Almost one-third (30%) of all puskesmas in 2003 were reported to have received training and
certification in Basic Emergency Obstetric and Neonatal Care (BEONC). This indicator was not
reported in 2004 or 2005 so any trend in BEONC coverage cannot be assessed.

Provincial Reproductive Health & MPS Profile of Indonesia

41

WEST SUMATRA
HEALTH PERSONNEL
Number
Coverage
(minimum standard)
Rows bordered in red are below minimum standard

2005
Indonesia miniCoverage
mum standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

Hospitals with CEONC

19 2

16

27 2
Not reported

1 CEONC hospital /
district

<1 / district
(WHO minimum stan- 1.7 / 500,000 pop.
dard:
one / 500,000 pop.)

In-hospital OBGYN

33 4

26 4

--

1 / 1806 pregnant women

In-hospital pediatricians

30

19

--

1 / 1968 newborn

Puskesmas
(primary health centers)

205 3

One PHC / 30,000


pop.

1 / 22,458 pop.

General practitioner in Puskesmas

198 3

--

1/ 23,252 pop.

Puskesmas with bed

63 3

--

31% of all puskesmas

4 / district
Puskesmas BEONC

62 3

30% of all puskesmas

Average 3/district; 4/16


(WHO minimum standistricts have none
dard:
One / 125,000 pop.)
1 / 74,257 pop.

Comprehensive Emergency Obsetric and Neonatal Care, 24 hour service.


From provincial website: http://sumbar.bps.go.id. HMIS did not report these data in 2001, 2002, 2004 and 2005. In 2003,
the HMIS reported 18 public and 19 private hospitals.
3
Source: HMIS 2003.
4
Source: HMIS 2005.
1
2

The current Indonesian recommended standard for BEONC facilities is 4 BEONC facilities in
every district. On average, there are sufficient BEONC by population, but West Sumatra would
require a total of 76 BEONC facilities to meet the four per district standard. Furthermore, the
distribution of BEONC (as reported in 2003) leaves some districts under-served compared to others. Mentawai, Kota Pariaman, Bukit Tinggi, and Padang Pajang report no BEONC facilities
(all less than 100,000 population), and Padang has only four BEONC facilities when its population requires 6 to 7.

Health Personnel
Similar to health facility data, West Sumatra has not reported complete health personnel data
from 2001 to 2005. The only complete data set describing health personnel is for 2003, therefore,
changes over time in health personnel coverage are impossible to determine from these data.
The total number of specialists in South Sumatra (reported in 2005) is good one Ob/Gyn for every
78,000 and one pediatrician for every 94,000 people. According to the 2003 data reported, there
are more midwives living in the village than villages, suggesting that all villages should have at
least one. However, only one-third (37%) of all midwives have a safe delivery kit, and the number
of midwives who are trained in APN or LSS is not reported.

42

OB/GYNs
Pediatricians
Primary health center general practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in LSS
Total TBA
Trained TBA
TBA with kit

--

1
2

59 1
49 1

Source: HMIS 2005.


Source: HMIS 2003.

198 2

1 / 23,252 population

193 2

--

2582 2

1 / 1782 population

1079 2

> 100% of villages

966 2
Not reported
Not reported
3701 2
3106 2
2607 2

1 / 4766 population
--84% of all TBA
70% of all TBA

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.
Assuming a crude birth rate in 21.8, the reported pregnancies are 5% lower than the estimated
pregnancies. Total deliveries were not reported by West Sumatra, but reported live births were
consistent with reported pregnancies. Where total deliveries are needed for indicator calculations, they were assumed to be 94.7% of all reported pregnancies, according to the Indonesia
average as calculated from all HMIS data (2005).
DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported /
estimated 1

Reported pregnancies

106,566

2.31% of total population

95.7

Estimated deliveries (none


reported)

100,909

94.7% of reported pregnancies

--

Reported newborn

96,445

95.9% of reported deliveries

--


Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
The formula for estimated deliveries is: (total population * crude birth rate * 1.05)/1000. However, 2005 population was not
reported by district in the HIS or in the website, so the multiplier of 94.7% of reported pregnancies was used to estimate total
deliveries, and by disirict. This multiplier reflects all reported deliveries in Indonesia as a proportion of reported pregnancies.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.

Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Provincial Reproductive Health & MPS Profile of Indonesia

WEST SUMATRA
Antenatal Coverage
Among reported pregnancies, over 91% of the women attend at least one antenatal visit (ANC1).
This drops to 81% coverage of 4 total antenatal visits (ANC4). Although ANC1 coverage is relatively good, the difference between ANC4 and ANC1 shows that nearly 12,000 women who
have accessed antenatal care once do not
obtain the minimum standard of antenatal
Antenatal Care Coverage 2005
care. These women are either not adhering to the recommended antenatal schedANC1 & 4
ule or are accessing ANC too late to reach
80%
4 visits. Quality of care, community awareness, and logistical accessibility factors
no ANC
likely account for these missed opportuniANC1 only
9%
11%
ties. Over 9,500 pregnant women (9%)
never access any antenatal care.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in West Sumatra. More than 96% of women report having an abdominal
examination, nearly 90% report having their blood pressure taken, and over 85% report having
their weight measured and receiving iron tablets. However, fewer than 39% report being informed
of signs of pregnancy complications; only 31% report giving a blood sample.
There is minimal variation in reported antenatal coverage by most districts, however, two districts, Mentawai and Kota Pariaman, do show substantially lower rates of ANC1 (51% and 65%
respectively) and Solok Selatan shows lower rates of ANC4 (62%) compared to the provincial
average.

Skilled Birth Attendance

According to the IDHS, nearly 59% of


women in West Sumatra deliver in a
health facility (mostly private) and 41%
deliver at home. Over 16% of women
deliver with a doctor. Attendance with
a nurse/midwife (63%) is also higher
than the national average. Nearly 20%
deliver with a TBA, relative or other person.
Only one district, Solok Selatan
(53%), reports lower skilled birth attendant coverage rates compared to the provincial average.
Trends in ANC4 and SBA coverage from 2002-2005 (no data on these indicators in 2001) show
some increase in ANC4 coverage (from 74% to 81%) and SBA coverage (from 68% to 78%).

Postpartum (Neonatal) Care Coverage


The IDHS estimates that just over 63% of
all births are officially registered in West
Sumatra. Although this is higher than the
national estimated level (53%), it is still
low.
Over 86% of all reported newborn attend the first neonatal visit (KN1), and
about 79% attend the second (KN2).
The IDHS found slightly lower rates of
early postpartum/neonatal care seeking and higher rates of never attending
postnatal care (19%).
Solok Selatan reports lower neonatal
coverage rates (KN1: 71%) than the
provincial average. Pesisir Selatan
has reasonable KN1 coverage (87%)
but drops to only 29% KN2 coverage.

Nearly 78% of all reported deliveries are


attended by a skilled health professional
(SBA=skilled birth attendant). This leaves
over 22,000 women delivering without any
skilled birth attendant. The national target
for skilled birth attendance is 82% by 2007
and 90% by 2010.

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate
of pregnant women detected as at risk by the community, including cadres, TBAs or other lay
persons (i.e. non-health professionals). Indonesia adopted that 20% of all pregnant women will
experience some complication of pregnancy, including a recognizable risk factor for poor ma-

Provincial Reproductive Health & MPS Profile of Indonesia

43

WEST SUMATRA
ternal or fetal outcome. Therefore over
21,000 pregnant women are expected
to be at risk in West Sumatra annually
(20% of all pregnant women reported).

The number of reported stillbirths and neonatal deaths indicate serious under-reporting. Based
on reported data (only available from 2003), West Sumatra has a neonatal mortality rate of only
5.7 compared to a national estimate of 18 neonatal deaths per 1000 births (WHO, 2006), less
than 1/3 of the country overall. Reported neonatal deaths also lower than IDHS (2002/2003) that
indicate 29/1000 births.Therefore, it is unlikely that the West Sumatra data on neonatal mortality
are accurate enough to utilize as an outcome indicator, though the actual death rate may indeed
be lower than the national average.

Overall, only 22% of these high risk


women were detected as being at risk
by community members and 69% were
detected by a health provider.
Just over 5% of expected maternal
complications were managed by the
health care system, at primary health care or tertiary levels. The national target for maternal
complication management is 60% by 2007 and 80% by 2010. West Sumatra is far below national
expectations on this indicator.
Management of neonatal complications appears to even lower. While the national target for
2007 is 60%, increasing to 80% in 2010, West Sumatra reports managing only 2% of expected
neonatal complications.

The reported stillbirth rate is 6.5 in West Sumatra compared to the national estimate of 17. The
ratio of SB to early neonatal deaths is 1.2 which is also the national estimate, suggesting reasonable accurate classification of stillbirths and neonatal deaths, despite overall under-reporting.

Hospital Management of Maternal and Neonatal Complications

Maternal and Neonatal Deaths

Reported data from hospitals in West Sumatra indicate that less than 4% of all deliveries occur in hospital. Over half (55%)
of these deliveries are classified as complicated.

The maternal mortality ratio can only be


calculated for 2003 due to lack of reporting these data in other years. There were
110 maternal deaths reported in 2003,
with an estimated maternal mortality ratio (MMR) of 110. This is smaller than
national estimates (MMR=230, range 58
to 440, WHO/UNICEF/UNFPA, 2000 or
MMR=307, IDHS, 2002/3) and suggest
some under-reporting.
Maternal Mortality Ratio 2003

(deaths / 100,000 reported newborn;


The predominant cause of maternal
no death data available for 2001, 2002, 2004, 2005)
death in West Sumatra is bleeding,
140
though eclampsia plays a significant
115
120
role. Key interventions to reduce risk
100
80
of hemorrhage should be emphasized
60
(iron deficiency anemia control, trained
40
midwives, appropriate use of oxytocics,
20
access to safe blood transfusion/fluid
0
2001
2002
2003
2004
2005
replacement). Women with signs or
symptoms of hypertensive disorders of
pregnancy should be strenuously referred to specialist care at a tertiary hospital, since early delivery by c-section is the most effective
measure to prevent progression to eclampsia and death.

44

The ratio of early to late neonatal deaths is consistent with international estimates, with over
75% of all neonatal deaths occurring in the first 7 days of life. This suggests the importance of
improving quality and access to pregnancy care, safer delivery and emergency neonatal care
(e.g. resuscitation, infection prevention, early detection and treatment, and management of low
birth weight newborn).

The case fatality rate for hospital obstetric


admissions / complications is low at 0.2%.
The proportion of maternal deaths that occur in hospital could not be calculated for
2004 due to lack of reporting of total maternal deaths that year. These data do not allow for more detailed analysis of how long after admission the mother died. This information would reflect whether interventions needed to reduce
maternal deaths should emphasize hospital practices / quality of care or community preparedness in recognizing risk and making timely referrals.
Nearly 22% of all hospital admissions are due to abortion, indicating a high rate of unsafe abortion practices in West Sumatra. Due to the high rate of complicated cases handled in hospital,
33% of all deliveries in hospital are by caesarean section. This can reflect an unnecessarily high
c-section rate. Indeed, the c-section rate over all deliveries in the province is very low (1.2%) and
suggests that there are many women delivering outside of hospitals who would have had better
outcomes if delivered by c-section.

Provincial Reproductive Health & MPS Profile of Indonesia

WEST SUMATRA
Recommendations

Data quality and reporting

1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Ensure minimum standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Ensure that sufficient midwives have received APN and LSS training. Ensure that every
puskesmas has at least one trained ANC midwife. It is important to aggressively upgrade
the technical skills of those attendants and ensure adequate access to well-prepared facilities.
4. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they
drop out?
5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
8. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
9. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.
HOSPITAL CASES

Number

% of hospital cases

OB/GYN cases treated at hospital (includes


normal deliveries)

3691

--

2026

54.9

--

0.2

--

Hospital admissions due to abortion

800

21.7

--

Caesarean sections

1213

32.9

1.2% of all deliveries

Complicated OB/GYN cases treated at hospital


2

Case fatality rate

Coverage 2004 1
3.5% of all pregnancies

Denominators from 2004 data were pregnancies: 103,989; deliveries: 98,809.


2
Excludes c-sections from the denominator, although deaths reported in the c-section column are included in the numerator.
1

10. Investigate reasons behind lack of data reporting in many years, and incomplete data in
other years. Data on population, deliveries, health facilities, health personnel and mortality
is often missing completely.
11. Invest in re-training and re-invigorating health officials at all levels on improving the quality
and completeness of all health data reported.
12. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
13. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
14. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.
BEONC UNMET NEED ACCORDING TO STANDARDS
Total UnWHO recTotal
#
Unmet
met Need Pop. / ommended
District
popula- BEONC
need
(MOH: BEONC coverage
tion
in 2005
(WHO)
4 / district)
(1 / 125,000)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

Pesisir Selatan (Pessel)


Kab Solok
Swl/Sijunjung
Tanah Datar
Padang Pariaman
Agam
Lima Puluh Kota (50 Kt)
Pasaman
Mentawai
Kota Padang
Kota Solok
Sawalunto (SWL)
Padangg Panjang
Bukit Tinggi
Pyakumbuh
Kota Pariaman
Pasaman Barat
Solok Selatan
Dhamasraya
TOTAL

Provincial Reproductive Health & MPS Profile of Indonesia

417,706
457,389
343,819
339,216
375,583
428,433
324,528
555,486
67,375
787,740
55,709
53,837
44,699
100,254
104,377
75,406
---4,531,557

Not reported

Coverage of health personnel and service inputs

--

(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
Up to 76

---------------------

(3)
(4)
(3)
(3)
(3)
(3)
(3)
(4)
(1)
(6)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
38 - 41

---------------------

45

WEST SUMATRA
COVERAGE OF MIDWIFE PERSONNEL
Total reported de- Total APN mid- Total LSS midliveries
wives
wives

District
1 Pesisir Selatan (Pessel)
2 Kab Solok
3 Swl/Sijunjung
4 Tanah Datar
5 Padang Pariaman
6 Agam
7 Lima Puluh Kota (50 Kt)
8 Pasaman
9 Mentawai
10 Kota Padang
11 Kota Solok
12 Sawalunto (SWL)
13 Padangg Panjang
14 Bukit Tinggi
15 Pyakumbuh
16 Kota Pariaman
17 Pasaman Barat
18 Solok Selatan
19 Dhamasraya

9,152

TOTAL

KEY INDICATORS AND NATIONAL TARGETS

7,817
4,171
6,516
8,742
9,019
7,455
5,343
1,651
17,533
1,321
1,212
938
2,200
2,389
1,683
7,198
2,901
3,669

Not reported

Not reported

100,909

West Sumatra
2001

2005 *

ANC1 (K1)

Not reported

91

ANC4 (K4)

Not reported

SBA deliveries

National Target
2007

2010

81

84

95

Not reported

78

82

90

Postpartum / Neonatal visit (KN1)

Not reported

86

83

90

Risk detection of pregnant women by community

Not reported

21.7

Obstetric complications managed

Not reported

5.3

60

80

Neonatal complications managed

Not reported

2.2

60

80

Caesarian section rate (% of hospital deliveries)

31.8

32.9 *

Caesarian section rate (% of reported deliveries)

2.2

1.2 *

Hospital OB/GYN cases as % of all pregnancies

6.5

3.5 *

Not reported

Not reported

Maternal Mortality Ratio


* c-sections and hospital data from 2004.

46

Provincial Reproductive Health & MPS Profile of Indonesia

RIAU

he total population of Riau is 4.4 million, accounting for 2% of the total


population in Indonesia, and over 9%
of the population in Sumatra. Riau is
divided into 11 districts (9 kabupaten + 2 kota
[cities]) with a total of 1482 villages. The capital is Pekanbaru. Riau Islands were made into
a separate province called Kepri (Kepulauan
Riau) in 2004. Much of the data reported here
for Riau from the IDHS or the BPS, however,
still includes the Riau Islands.

GEOGRAPHY
Total land area (km2)

87,844

Number of districts

11

Kabupaten (regencies)

Kota (municipalities)

Kecamatan (sub-districts)

144

Kelurahan/Desa (villages)

1482

Source: Beberapa Indicator Penting Social-Ekonomi Indonesia, Edisi Juli 2006, BPS.

Riau has a similar urban population (50%) and lower poor population (12%) compared to the
national average. Adult female literacy is higher than the national rate at 96%.
SOCIAL DEMOGRAPHY

Riau

National

4,385,216

220,659,431

Percent urban population (2005) 2

50

48

Percent poor population (2004)

12

17

96

87

65

116

Life expectancy at birth (2002) 2

Male: 66
Female: 70

Male: 64
Female: 68

Annual growth rate (2000-2005) 2

4.30

1.34

1,027,890 3

51,732,453 4

3.2

2.6

24.8

22.0

8.5

10.4

Modern contraceptive prevalence (%) 6

55.7

56.7

Unmet need for contraception (%)

10.4

8.6

Total population (2005) 1


2

Adult female literacy rate (2004) 2


Population density (km sq.; 2005)

Women of reproductive age


Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing
6

Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.


Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
2
3

The total fertility rate (3.2) and crude birth rate


(24.8) are similar to the national average. The
modern contraceptive prevalence rate is also similar (56%) and the percentage of young women who
have begun childbearing is slightly lower than the
national average (8.5%).
Among all contraceptive users, most women choose
injection (52%) or oral contraceptives (31%). Other
methods include IUD (5%), implants (4%) or traditional methods (4%).

Health Facilities
Riau reports 31 hospitals 12 public and 19 private. There are at least 27 OB/Gyn specialists
and at least 27 pediatricians working in almost all public and private hospitals. These indicators
may be higher since five districts did not private hospital data.
Nearly all hospitals (28) are certified as providers of Comprehensive Emergency Obstetric and
Neonatal Care (CEONC).
Riau has 155 puskesmas (primary health centers) with even more puskesmas-based general
practitioners (163). More than one in four puskesmas (28%) has a bed for in-patient care. The
population covered by each puskesmas, on average, meets the recommended standard.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 32 puskesmas (21%) are reported to have received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC), with about 2-3 in each district. The current World
Health Organization (WHO) recommended standard for BEONC facilities is 1 per every 125,000
people. Indonesia has adopted this indicator, but translated it to mean at least 4 BEONC facilities for each district.
The population coverage of BEONC facilities in Riau almost meets the standard. However, 13
additional BEONC facilities are needed to reach 4 per district; only 6 additional facilities would

Provincial Reproductive Health & MPS Profile of Indonesia

47

RIAU
HEALTH FACILITIES

2005

Indonesia minimum
standard

Public Private

Coverage

Rows bordered in red are below minimum standard


Total hospitals (general)

Hospitals with CEONC

12

19

Not reported

28

--

1 CEONC hospital / district


(WHO minimum standard:
one / 500,000 pop.)

>2 / district
>3 / 500,000 pop.

HEALTH PERSONNEL
%
2001
2005
Coverage
(minimum standard)
Change
Rows bordered in red are below minimum standard
OB/GYNs

Not reported

80 1

--

Pediatricians

Not reported

67 1

--

Primary health center general practitioners


(One GP / 30,000 pop.)

Not reported

484 2

--

Nurses trained in ANC

Not reported

49 3

--

Total midwives
(One / 3000 pop.)

372

1512

306%

1 / 2900 population

186

585

215%

39% of villages have


village midwife

1 / 9060 population

In-hospital OBGYN

11 3

16 2

--

1 / 4784 pregnant women

In-hospital pediatricians

12

17 2

--

1 / 4027 newborn

One PHC / 30,000 pop.

1 / 28,292 pop.

Midwives living in the village


(One / village)

186

629

238%

Midwives trained in APN

Not reported

31

--

2% of midwives

Midwives trained in LSS

Not reported

--

--

Total TBA

Not reported

1983

Trained TBA

Not reported

432

TBA with kit

Not reported

1071 6

Puskesmas
(primary health centers)

155

General practitioner in
Puskesmas

163

--

1 / 26,903 pop.

Puskesmas with bed

44

--

28% of all puskesmas

4 / district
Puskesmas BEONC

32

(WHO minimum standard:


One / 125,000 pop.)

21% of all puskesmas


Average 2.9/district
1 / 137,038 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.


Five of 11 districts (Kampar, Indragiri Hulu, Indragiri Hilir, Kiantan Singingi, Siak) did not report these data.
3
One district (Siak) did not report these data.
1
2

be needed to meet the recommendation of 1/125,000 population.

While BEONC coverage is quite good in Riau compared to most provinces in Indonesia, the
population coverage standards could be easily met by upgrading each puskesmas with a bed
to BEONC standards. The cost per puskesmas team (3 persons) to be trained in BEONC is 9.3
million (3.1 per person).

Health Personnel
The total number of specialists in Riau shows good coverage with more than one Ob/Gyn for
every 55,000 population and one pediatrician for every 65,000 population.
The reported total number of GPs is more than double that reported in 2004, suggesting an error
in HIS reporting. If the 2005 data are true, there is one GP for every 9000 residents in Riau. If the
2004 data are closer to the truth, there is one for every 19,000 residents. Either way, Riau meets
the recommended standard.
Population coverage of midwives also meets the recommended standard of 1/3000. However,
only 39% of all villages report having a midwife living in the village. Only 2% of all midwives have
received APN training and none are reported to have received LSS training. Given the good coverage of specialists and GPs, the very low proportion of trained midwives is either a data reporting
error, or is a problem that should be addressed immediately.

48

Midwives with a kit

4
5

1 / 6972 population

---

--

--

--

One district (Bengkalis) did not report this indicator.


This total number of GPs is questionable data, leading to an extremely high ratio of GPs to population compared to the
standard. Only 229 were reported in 2004 which is more realistic (1/19,000 pop.)
3
Ten out of 11 districts did not report these data (only district reporting was Rokan Hilir).
4
Four out of 11 districts (Kampar, Pelalawan, Dumai, Bengkalis) did not report this indicator.
5
Seven out of 11 districts (Pekanbaru, Kampar, Pelalawan, Siak, Dumai, Bengkalsi, Rokan Hulu) did not report this indicator.
6
Six out of 11 districts (Pekanbaru, Kampar, Pelalawan, Siak, Bengkalsi, Rokan Hulu) did not report this indicator.
1
2

Primary Health Care Indicators


DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported /
estimated 1

Reported pregnancies

129,160

2.95`% of total population

107.0

Reported deliveries

120,176

93.0% of reported pregnancies

105.2

Reported newborn

116,771

97.2% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.
Assuming a crude birth rate in Riau of 24.8 (BPS, 2000), the reported pregnancies are about 7%
higher than the estimated pregnancies, and reported deliveries about 5% higher than estimated

Provincial Reproductive Health & MPS Profile of Indonesia

RIAU
deliveries. The proportion of deliveries to pregnancies is also a bit lower than expected. These
discrepancies suggest that there may be some errors in counting vital events in Riau. Other explanations could be that the crude birth rate or population is higher than estimated.

Antenatal Care Coverage


Among reported pregnancies, 93% of the women
attended at least one antenatal visit (ANC1). This
drops to 84% coverage of 4 total antenatal visits
(ANC4), which meets the 2007 target. Although
ANC1 coverage is relatively good, the small difference between ANC4 and ANC1 means that
nearly 12,000 women who have accessed antenatal care once do not obtain the minimum standard of 4 antenatal visits. These women are either not adhering to the recommended antenatal schedule or are accessing ANC too late to reach
4 visits. Quality of care, community awareness, and logistical accessibility factors likely account
for these missed opportunities. Nearly 10,000 pregnant women never accessed any antenatal
care in Riau.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in Riau. More than 94% of women report having an abdominal examination;
about 91% reported having their blood pressure taken, and 80% report having their weight measured. However, only 71% received iron tablets, 28% report being informed of signs of pregnancy
complications and 36% report giving a blood sample. Although reported antenatal attendance is
relatively high in Riau, the above data suggest that the quality of care may be less than optimal.

The IDHS estimated (2002/3) that nearly


12% of women are attended by a doctor
at delivery; 62% by a nurse midwife, and
23% by a TBA, relative or other attendant.
More than one-third (37%) delivered at a
health facility (mostly private), and 60%
delivered at home (IDHS).
There is minimal variation in reported
SBA coverage by most districts, however, three districts, Indragiri Hilir, Rokan
Hulu and Rokan Hilir, reported lower
rates of SBA coverage (61%, 56% and
60% respectively) compared to the provincial average.
Antenatal coverage and SBA attendance
since 2001 show inconsistent but increasing trends between 2001 2005 on
each indicator. Antenatal attendance (ANC4) appears to have increased about 5 percentage
points, while SBA coverage has increased about 6 percentage points.

Postpartum (Neonatal) Care Coverage

There is minimal variation in reported antenatal coverage by most districts. One district, Indragiri
Hulu, was excluded from the ANC1 calculation due to suspected under-reporting (16% ANC1 but
77% ANC2).

Skilled Birth Attendance


About 72% of all reported deliveries are attended by a skilled health professional (SBA=skilled birth
attendant). This leaves over 34,000 women delivering without any skilled birth attendant. This coverage is below the recommended target for 2007 (82%).

The IDHS estimates that only 65% of all births are officially registered in Riau, higher than the
national average, but still low. Nearly 4 out of 5 (78%) of all reported newborn attend the first
and second neonatal visits (KN1, KN2) and 5% attend KN1 only. The IDHS found slightly lower
rates of postpartum/neonatal care attendance, and slightly higher rates of missing care altogether
(21%).

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate of
pregnant women detected as at risk by the community, including cadres, TBAs or other lay perProvincial Reproductive Health & MPS Profile of Indonesia

49

RIAU
sons (i.e. non-health professionals). Indonesia adopted that 20% of all pregnant
women will need medical attention during
pregnancy or delivery, or nearly 26,000
pregnant women in Riau annually (20% of
all pregnant women reported).

actively referred to specialist care at a hospital, since early delivery by c-section is the most effective measure to prevent progression to eclampsia and death.
It should be noted that one-third (33%) of all maternal deaths are not attributed to any immediate cause of death. More importance should be attached to correctly diagnosing and recording
causes of maternal deaths in order to more closely track progress toward effective management
of obstetric complication and identify potential interventions to reduce maternal mortality.

Overall, only 10% of this total number of


women were detected as being at risk by
community members, though 61% were
detected by a health provider (denominator adjusted, applicable to reporting districts only).

The number of reported stillbirths and neonatal deaths indicate serious under-reporting. Based
on reported data, Riau has a neonatal mortality rate of only 6.4 compared to a national estimate
of 18 neonatal deaths per 1000 births (WHO, 2006). Reported neonatal deaths is also lower the
IDHS 2002/2003, that is 26 / 1000 births. Therefore, it is unlikely that the Riau data on neonatal
mortality are accurate enough to utilize as an outcome indicator.

Less than 13% of all expected maternal complications (20% of pregnancies) were managed by
the health care system at primary or tertiary levels of care. The national target for obstetric complications management is 60% by 2007 and 80% by 2010. Riau is below national expectations
on this indicator.

The ratio of reported early to late neonatal deaths reflects likely errors in data reporting. Riau
reported only 42% early deaths as a proportion of all neonatal deaths. In Indonesia, about threequarters of all neonatal deaths occur in the first 7 days of life suggesting the importance of improving quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g.
resuscitation, infection prevention, early detection and treatment of sepsis, and management of
low birth weight newborn).

Management of neonatal complications (estimated to be 25% of newborn born) appears to be


significantly lower. While the national target for 2007 is 60%, increasing to 80% in 2010, Riau
reports managing less than 0.5% of all expected neonatal complications.

Maternal and Neonatal Deaths


There were 157 maternal deaths reported in Riau in 2005, nearly 4% of
all reported maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is low at 134 / 100,000
live births. This is far smaller than national estimates (MMR=230, range 58
to 440, WHO/UNICEF/UNFPA, 2000
or MMR=307, IDHS, 2002/3) and suggests significant under-reporting.

Hospital Management of Maternal and Neonatal Complications


Causes of Maternal Deaths, 2005
bleeding
48%
other /
unknown
33%

eclampsia
18%

infection
1%

Maternal Mortality Ratio 2001-05

The predominant cause of maternal


(deaths / 100,000 reported newborn)
death in Riau is bleeding, though ec300
lampsia also plays a significant role.
247
250
Key interventions to reduce risk of
200
160
150
hemorrhage should be emphasized
134
150
(iron deficiency anemia control, trained
100
57
midwives, appropriate use of oxytocics
50
rd
in active management of 3 stage as
0
per national policy, access to safe blood
2001
2002
2003
2004
2005
transfusion/fluid replacement). Women
with signs or symptoms of hypertensive disorders of pregnancy should be treated properly and

50

The reported stillbirth rate is 4.3 / 1000 estimated deliveries in Riau compared to the national
estimate of 17.

Reported data from hospitals in Riau indicate that about 4% of all deliveries occur in hospital.
Nearly half (47%) of these deliveries are classified as complicated.
The case fatality rate for complications is low at 0.3%, but only 4% of reported maternal deaths
occurred in hospital.
Number

% of Hospital
Cases

OB/GYN cases treated at hospital


(includes normal deliveries)

5370

--

Complicated OB/GYN cases treated


at hospital 2

2358

47.3

--

0.27

4.1% of reported maternal


deaths (169 in 2004) occurred in
hospital

Hospital admissions due to abortion

959

17.9

--

Caesarean sections

1137

21.2

1.0% of all deliveries

HOSPITAL CASES

Case fatality rate 3

% Coverage
(reported pregnancies) 1
4.3% of all pregnancies

Denominators from 2004 data were pregnancies: 124,875; deliveries: 117,937.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Provincial Reproductive Health & MPS Profile of Indonesia

RIAU
Nearly 18% of all hospital admissions are due to
Obstetric Complications at Hospital 2004
abortion, suggesting a high rate of unsafe aborinfection
0.6%
tion practices in Riau. Only 21% of all deliveries
abortion
37%
in hospital are by caesarean section, despite the
eclampsia
other /
high rate of complications among hospital deliv15%
unknown
bleeding
28%
19%
eries and low rate of hospital deliveries overall.
The c-section rate over all deliveries in the province is low at about 1% and suggests that there
are some women delivering outside of hospitals
who would have had better outcomes if delivered by c-section. Internationally, from 5-15% of
women are expected to require delivery by c-section for optimal maternal/neonatal outcome.

Recommendations

2. Increase the number of midwives who have received APN and BEONC training, particularly
in districts reporting none. Ensure that every puskesmas has at least one trained ANC
midwife. With nearly adequate presence of BEONC facilities, the rate of reported trained
midwives seems very low.
BEONC UNMET NEED ACCORDING TO STANDARDS

2
3
4
5
6
7
8
9
10
11

Total Un#
Total popumet Need
BEONC
lation
(MOH:
in 2005
4 / district)

Pop. /
BEONC

WHO
recommended
coverage
(1 /
125,000)

Unmet
need
(WHO)

6. Improve classification of maternal deaths by cause to reduce the proportion reported as


unknown.

8. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
9. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
10. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

COVERAGE OF MIDWIFE PERSONNEL


Total reported
District
deliveries

658,576

164,644

Kampar

532,468

266,234

Pelalawan

230,665

115,333

Indragiri Hulu

145,491

48,497

Indragiri Hilir

615,615

153,904

Kuantan Singingi

244,444

122,222

Siak

296,252

148,126

Dumai

215,749

107,875

Bengkalis

668,824

167,206

Rokan Hulu

340,691

170,346

Rokan Hilir

436,441
4,385,216

5
32

0
13

87,288
137,038

4
35

0
6

TOTAL

5. Improve management of obstetric and neonatal complications. Community awareness of


pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.

Data quality and reporting

1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.

1 Pekanbaru

4. Increase the proportion of newborn and postpartum mothers who receive postnatal care.

7. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Coverage of health personnel and service inputs

District

3. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.

Total APN midwives

Total BEONC
midwives

1 Pekanbaru

17,979

2 Kampar

14,536

5,536

4 Indragiri Hulu

7,905

5 Indragiri Hilir

16,804

6 Kuantan Singingi

6,655

7 Siak

7,702

3 Pelalawan

8 Dumai

5,609

9 Bengkalis

17,390

10 Rokan Hulu

8,645

11 Rokan Hilir

11,415

120,176

31
(1 / 3877 deliveries)

Provincial Reproductive Health & MPS Profile of Indonesia

TOTAL

51

RIAU
KEY INDICATORS AND NATIONAL TARGETS

Riau

National Target

2001

2005 *

2007

2010

ANC1 (K1)

88

93

ANC4 (K4)

78

84

84

95

SBA deliveries

65

72

82

90

Postpartum / Neonatal visit (KN1)

68

83

83

90

Risk detection of pregnant women by community

2.6

10.5

Obstetric complications managed

Not reported

12.6

60

80

Neonatal complications managed

Not reported

0.4

60

80

Caesarian section rate (% of hospital deliveries)

30

21 *

Caesarian section rate (% of reported deliveries)

1.3

1.0 *

Hospital OB/GYN cases as % of all pregnancies

4.2

4.3 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

57

137

* c-seions and hospital data from 2004

52

Provincial Reproductive Health & MPS Profile of Indonesia

JAMBI

he total population of Jambi is 2.6 million,


accounting for nearly 1% of the total population in Indonesia, and nearly 6% of the
population in Sumatra. Jambi is divided
into 10 districts (9 kabupaten + 1 kota [city]) with a
total of 1231 villages. The capital is Jambi city.
Jambi has a lower urban population (32%) and
lower poor population (12%) compared to the national average. Adult female literacy is higher than
the national rate at 94%.

GEOGRAPHY
Total land area (km2)

45,348

Number of districts

10

Kabupaten (regencies)

Kota (municipalities)

Kecamatan (sub-districts)

94

Kelurahan/Desa (villages)

1231

Source: Beberapa Indikator Penting Sosial-Ekonomi


Indonesia, Edisi Juli 2006, BPS.

The total fertility rate (2.7) and crude birth rate (25.2) are similar to the national average. The
modern contraceptive prevalence rate is also similar (58%) but the percentage of young women
SOCIAL DEMOGRAPHY

Jambi

National

2,610,140

220,659,431

32

48

Percent poor population (2004) 2

12

17

Adult female literacy rate (2004) 2

94

87

Population density (km sq.; 2005) 2

50

116

Life expectancy at birth (2002) 2

Male: 65
Female: 69

Male: 64
Female: 68

Annual growth rate (2000-2005) 2

2.00

1.34

611,820 3

51,732,453 4

2.7

2.6

Crude birth rate / 1000 pop. (2000) 5

25.2

22.0

Percentage of women 15-19 who have begun childbearing 6

17.6

10.4

Modern contraceptive prevalence (%) 6

57.9

56.7

Unmet need for contraception (%)

6.1

8.6

Total population (2005) 1


Percent urban population (2005)

Women of reproductive age


Total fertility rate / 1000 women

From provincial health data reports.


2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

who have begun childbearing is higher than the national average (17.6%). Among all contraceptive
users, most women choose injection (49%), oral
contraceptives (26%), implants (13%) or IUD (8%).

Health Facilities
HEALTH FACILITIES

2005
Public

Private

Indonesia minimum
standard

Coverage

Rows bordered in red are below minimum standard


Total hospitals (general)

10

-1 CEONC hospital /
district

Hospitals with CEONC 1

Not reported

In-hospital OBGYN

11

--

1 / 5868 pregnant
women

In-hospital pediatricians

--

1 / 7805 newborn

(WHO minimum standard:


one / 500,000 pop.)

<1 / district
>1 / 500,000 pop.

Puskesmas
(primary health centers)

138

One PHC / 30,000 pop.

1 / 18,914 pop.

General practitioner in
Puskesmas

163

--

1/ 16,013 pop.

Puskesmas with bed

32

--

23% of all puskesmas


4% of all puskesmas

4 / district
Puskesmas BEONC

1
2

62

(WHO minimum standard:


One / 125,000 pop.)

Average <1/district;
5 of 10 districts have
none 2
1 / 435,023 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.


Five districts (Kota Jambi, Bungo, Batanghari, Tj. Timur, Kerinci) did not report this indicator, or have none.

Provincial Reproductive Health & MPS Profile of Indonesia

53

JAMBI
Jambi reports only 18 hospitals 10 public and 8 private. There are 12 Ob/Gyn specialists and 8
pediatricians working mostly in public hospitals.
It appears that only 7 public hospitals are certified as providers of Comprehensive Emergency
Obstetric and Neonatal Care (CEONC) with only 7 of 10 districts reporting one; Tebo, Sarolangun and Tj. Timur report none.
Jambi has 138 puskesmas (primary health centers) with even more puskesmas-based general
practitioners (163). Nearly 1 in 4 puskesmas (23%) has a bed for in-patient care. The population
covered by each puskesmas, on average, meets the recommended standard.
HEALTH PERSONNEL
(minimum standard)

2001

2005

%
Change

Coverage

Rows bordered in red are below minimum standard


OB/GYNs

Not reported

13

--

Pediatricians

Not reported

--

241

Not reported

--

Not reported

--

Total midwives
(One / 3000 pop.)

1387

1103

20%

1 / 2366 population

Midwives living in the village


(One / village)

683

596

13%

48% of villages have


village midwife

Midwives with a kit

Not reported

531

--

1 / 4915 population

Midwives trained in APN

Not reported

78

--

7% midwives

Midwives trained in LSS

Not reported

--

Total TBA

Not reported

Not reported 1

--

Trained TBA

Not reported

Not reported 1

--

--

TBA with kit

Not reported

Not reported 1

--

--

Primary health center general


practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC

--

--

One immediate step would be to upgrade each puskesmas with a bed to BEONC standards,
focusing first on districts with no BEONC or CEONC facility (see those highlighted above). The
cost per puskesmas team (3 persons) to be trained in BEONC is 9.3 million (3.1 per person).

Health Personnel
The total number of specialists in Jambi is small with less than one Ob/Gyn for more than 200,000
population and one pediatrician for more than 370,000 population.
The total number of GPs was not reported, but if there are only those who work in puskesmas,
the recommended standard of 1/30,000 population is met. Population coverage of midwives also
meets the recommended standard of 1/3000. However, only 48% of all villages report having a
midwife living in the village. Only 7% of all midwives have received APN training and none are
reported to have received LSS training.

Primary Health Care Indicators


DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported /
estimated 1

Reported pregnancies

70,417

2.7% of total population

96.5

Reported deliveries

64,910

92.2% of reported pregnancies

94.0

Estimated newborn 2

62,443

--

--


Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
2
Reported newborn was same as reported deliveries, so estimated newborn (96.2% of deliveries; calculated from all reported
deliveries and newborn in Indonesia) was used as the denominator for indicators measuring coverage of newborn.
1

Only 3 districts reported this indicator.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 6 puskesmas (4%) are reported to have received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC), but only 5 of 10 districts reported this indicator. The
remaining five either have zero, or did not report their data (Kota Jambi, Bungo, Batanghari, Tj.
Timur, Kerinci).
The current World Health Organization (WHO) recommended standard for BEONC facilities is 1
per every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least
four BEONC facilities for each district.
Assuming that the five districts who did not report have zero BEONC facilities, the population cov-

54

erage of BEONC facilities in Jambi is far below the standard of 1/125,000. Up to 34 additional
BEONC facilities are needed to reach 4 per district; and up to 15 additional facilities would be
needed to meet the recommendation of 1/125,000 population.

The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in Jambi of 25.2 (BPS, 2000), the reported pregnancies are about 4%
lower than the estimated pregnancies, and reported deliveries about 6% lower than estimated
deliveries. The proportion of deliveries to pregnancies is also a bit lower than expected and the
district totals for reported newborn was identical to reported deliveries. These discrepancies suggest that there may be some problems with the counting or reporting of vital events in Jambi. For
indicator calculation in this profile, reported pregnancies and deliveries were retained, but total
newborn were estimated. The multiplier used to estimate newborn (reported deliveries x 94.4%)
was calculated from all reported deliveries and newborn in Indonesia.

Provincial Reproductive Health & MPS Profile of Indonesia

JAMBI
Antenatal Care Coverage
Among reported pregnancies, 91% of the women
attended at least one antenatal visit (ANC1). This
drops to 78% coverage of 4 total antenatal visits
(ANC4), which is below the 2007 target of 84%.
Although ANC1 coverage is relatively good, the
difference between ANC4 and ANC1 means that
nearly 9000 women who have accessed antenatal
care once do not obtain the minimum standard of
4 antenatal visits. These women are either not
adhering to the recommended antenatal schedule or are accessing ANC too late to reach 4 visits. Quality of care, community awareness, and logistical accessibility factors likely account for
these missed opportunities. Over 6000 pregnant women never accessed any antenatal care in
Jambi.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in Jambi. More than 93% of women report having an abdominal examination;
about 80% report having their blood pressure and weight measured. However, only 59% received
iron tablets, 25% report being informed of signs of pregnancy complications and 22% gave a
blood sample. Although reported antenatal attendance is high in Jambi, the above data suggest
that the quality of care may be less than optimal.
There is minimal variation in reported antenatal coverage by most districts, however, one district,
Sarolangun, reports lower rates of ANC4 (63%) compared to the provincial average.

Skilled Birth Attendance

report lower rates of SBA coverage (62%


and 64% respectively) than the provincial
average.
There is an inconsistent trend between
2001 2005, making it difficult to interpret without additional information about
programmatic initiatives or possible errors
in data reporting. SBA coverage appears
to have increased, particularly between
2004 and 2005, but a sudden jump of over
10% may be unlikely and could be due to
reporting errors.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that only 46% of all births are
officially registered in Jambi, lower than the national
average. Only 69% of all reported newborn attend
the first and second neonatal visits (KN1, KN2)
and 12% attend KN1 only. The IDHS found similar
rates of postpartum/neonatal care attendance, and
similar rates of missing care altogether (17%).

About 78% of all reported deliveries are attended by


a skilled health professional (SBA=skilled birth attendant). This leaves nearly 15,000 women delivering
without any skilled birth attendant. The national target for skilled birth attendance is 82% by 2007 and
90% by 2010.
The IDHS estimated (2002/3) that nearly 10% of
women are attended by a doctor at delivery; 61% by a nurse midwife, and 29% by
a TBA, relative or other attendant. More
than one-third (37%) delivered at a health
facility (mostly private), and 62% delivered
at home (IDHS).
There is minimal variation in reported SBA
coverage by most districts, however, two
districts, Sarolangun and Batanghari,

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate of
pregnant women detected as at risk by the community, including cadres, TBAs or other lay persons (i.e. non-health professionals). Indonesia adopted that 20% of all pregnant women will need
medical attention during pregnancy or delivery, or over 14,000 pregnant women in Jambi annually

Provincial Reproductive Health & MPS Profile of Indonesia

55

JAMBI
(20% of all pregnant women reported).

maternal deaths in order to more closely track progress toward effective management of obstetric
complication and identify potential interventions to reduce maternal mortality.

Overall, only 7% of this total number of


women were detected as being at risk by
community members and 55% were detected by a health provider (denominator
adjusted, applicable to reporting districts
only).

The number of reported stillbirths and neonatal deaths indicate serious under-reporting. Based
on reported data, Jambi has a neonatal mortality rate of only 3.3 compared to a national estimate
of 18 neonatal deaths per 1000 births (WHO, 2006). The reported neonatal deaths also lower
than IDHS (24/1000 births). Therefore, it is unlikely that the Jambi data on neonatal mortality are
accurate enough to utilize as an outcome indicator.

Less than 8% of all expected maternal


complications (20% of pregnancies) were
managed by the health care system at primary or tertiary levels of care. The national target for
obstetric complications management is 60% by 2007 and 80% by 2010. Jambi is below national
expectations on this indicator.
Management of neonatal complications (estimated to be 25% of newborn born) was not reported.
The national target for 2007 is 60%, increasing to 80% in 2010.

Maternal and Neonatal Deaths


There were 60 maternal deaths reported in Jambi
in 2005, about 1% of all reported maternal deaths
in Indonesia. The estimated maternal mortality ratio (MMR) is very low at 96 / 100,000 live births.
This is smaller than national estimates (MMR=230,
range 58 to 440, WHO/UNICEF/UNFPA, 2000 or
MMR=307, IDHS, 2002/3) and suggests significant under-reporting.

Causes of Maternal Deaths, 2005


other /
unknown
50%

bleeding
40%

infection
8%
eclampsia
2%

Maternal Mortality Ratio 2001-05


The predominant cause of maternal death
(deaths / 100,000 reported newborn)
in Jambi is bleeding. Key interventions to
reduce risk of hemorrhage should be em130
140
phasized (iron deficiency anemia control,
120
105
96
100
trained midwives, appropriate use of oxy80
59
tocics in active management of 3rd stage
51
60
as per national policy, access to safe
40
20
blood transfusion/fluid replacement). An0
other important cause of death in Jambi is
2001
2002
2003
2004
2005
infection (8%), which is higher than most
other provinces in Indonesia. Eclampsia,
usually the 2nd highest cause of death, is reported at a very low rate in Jambi (2%). Although
absolute numbers are small, these data are consistent with 2004 reports from Jambi and should
be investigated further.

It should be noted that one-half of all maternal deaths are not attributed to any immediate cause
of death. More importance should be attached to correctly diagnosing and recording causes of

56

The ratio of early to late neonatal deaths is not consistent with international estimates, with 60%
of all reported neonatal deaths occurring before the first 7 days. This means that early neonatal
deaths are more often missed than late neonatal deaths, though all neonatal deaths appear to
be under-reported. WHO estimates that three-quarters of all neonatal deaths in Indonesia occur
in the first week of life, suggesting the importance of improving quality and access to pregnancy
care, safer delivery and emergency neonatal care (e.g. resuscitation, infection prevention, early
detection and treatment, and management of low birth weight newborn).
The reported stillbirth rate is 4.2 / 1000 estimated deliveries in Jambi compared to the national
estimate of 17.

Hospital Management of Maternal and Neonatal Complications


HOSPITAL CASES

Number

% of Hospi% Coverage
tal Cases (reported pregnancies) 1

OB/GYN cases treated at hospital (includes


normal deliveries)

1096

--

1.6% of all pregnancies

Complicated OB/GYN cases treated at hospital 2

812

74.1

--

1.0

21% of reported maternal


deaths (39 in 2004) occurred
in hospital

Hospital admissions due to abortion

257

23.5

--

Caesarean sections

596

54.4

0.9% of all deliveries

Case fatality rate 3

Denominators from 2004 data were pregnancies: 70,474 deliveries: 65,839.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Reported data from hospitals in Jambi indicate that


fewer than 2% of all deliveries occur in hospital.
Nearly three-quarters (74%) of these deliveries are
classified as complicated.
The case fatality rate for complications is moderate
at 1.0% (WHO>1%) and 21% of reported maternal
deaths occurred in hospital.

Provincial Reproductive Health & MPS Profile of Indonesia

JAMBI
Nearly 24% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion practices in Jambi. Over half (54%) of all deliveries in hospital are by caesarean section. The
c-section rate over all deliveries in the province is low at less than 1% and suggests that there are
some women delivering outside of hospitals who would have had better outcomes if delivered by
c-section. Internationally, from 5-15% of women are expected to require delivery by c-section for
optimal maternal/neonatal outcome.

increasing health infrastructure to ensure equal access within the province.


11. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.
BEONC UNMET NEED ACCORDING TO STANDARDS
Total Un#
Total popmet Need
Pop. /
District
BEONC
ulation
(MOH:
BEONC
in 2005
4 / district)

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they
drop out?
4. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
5. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
6. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
7. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown. Investigate the possible high rate of infections, and deaths to infections.
8. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

WHO recommended coverage


(1 / 125,000)

Unmet
need
(WHO)

1 Kota Jambi

424,426

--

(4)

--

(3)

2 Bungo

248,603

--

(4)

--

(2)

3 Tebo

232,128

232,128

4 Sarolangun

194,653

194,653

5 Merangin

283,172

283,172

6 Tj. Barat

217,304

217,304

7 MA. Jambi

281,417

140,709

8 Batanghari

210,430

--

(4)

--

(2)

9 Tj.Timur

208,552

--

(4)

--

(2)

309,455

--

(4)

--

(2)

2,610,140

14 - 34

100,014

22

4 - 15

10 Kerinci
TOTAL

COVERAGE OF MIDWIFE PERSONNEL


Total reported
deliveries

District
1 Kota Jambi

11,147

Total APN midwives

Total LSS midwives

42

2 Bungo

6,582

3 Tebo

5,708

4 Sarolangun

4,878

5 Merangin

7,309

6 Tj. Barat

5,367

7 MA. Jambi

6,697

14

8 Batanghari

4,188

9 Tj.Timur

5,226

7,808

64,910

78
(1 / 832 deliveries)

10 Kerinci
TOTAL

Data quality and reporting


9. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
10. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in

Provincial Reproductive Health & MPS Profile of Indonesia

57

JAMBI
KEY INDICATORS AND NATIONAL TARGETS

Jambi

National Target

2001

2005 *

2007

2010

ANC1 (K1)

85

91

ANC4 (K4)

75

78

84

95

Error

78

82

90

51

81

83

90

Risk detection of pregnant women by community

Not reported

7.1

Obstetric complications managed

Not reported

7.6

60

80

Neonatal complications managed

Not reported

Not reported

60

80

Caesarian section rate (% of hospital deliveries)

20.0

54.4 *

Caesarian section rate (% of reported deliveries)

1.0

0.9 *

Hospital OB/GYN cases as % of all pregnancies

4.8

1.6 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

51

96

SBA deliveries
Postpartum / Neonatal visit (KN1)

* c-sections and hospital data from 2004.

58

Provincial Reproductive Health & MPS Profile of Indonesia

SOUTH
sUMATRA
The total population of South Sumatra is 7.7 million,
accounting for 3.5% of the total population in Indonesia, and 16% of the population in Sumatra. South
Sumatra is divided into 14 districts (10 kabupaten + 4
kota [cities]) with a total of 2780 villages. The capital
is Palembang.
South Sumatra has a lower urban population (39%)
and slightly higher poor population (20%) compared
to the national average. Adult female literacy is higher than the national rate at 94%.

GEOGRAPHY
Total land area (km2)

60,302

Number of districts

14

Kabupaten (regencies)

10

Kota (municipalities)

Kecamatan (sub-districts)

169

Kelurahan/Desa (villages)

2780

Source: Beberapa Indikator Penting Sosial-Ekonomi


Indonesia, Edisi Juli 2006, BPS.

SOCIAL DEMOGRAPHY

Health Facilities
HEALTH FACILITIES

7,708,534

220,659,431

Percent urban population (2005) 2

39

48

Percent poor population (2004) 2

20

17

94

87

73

116

Life expectancy at birth (2002) 2

Male: 64
Female: 68

Male: 64
Female: 68

Annual growth rate (2000-2005) 2

1.70

1.34

1,806,880 3

51,732,453 4

2.3

2.6

23.6

22.0

Percentage of women 15-19 who have begun childbearing 6

5.5

10.4

Modern contraceptive prevalence (%)

58.6

56.7

6.8

8.6

Adult female literacy rate (2004)

Population density (km sq.; 2005) 2

Women of reproductive age


6

Crude birth rate / 1000 pop. (2000)

Unmet need for contraception (%) 6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3

2005

Indonesia minimum
standard
Public Private

Total hospitals (general)

-1 CEONC hospital /
district

Not reported (WHO minimum standard:


one / 500,000 pop.)

<1 / district
<1 / 500,000 pop.

Hospitals with CEONC 1

In-hospital OBGYN

14

--

1 / 11,121 pregnant women

In-hospital pediatricians

11

--

1 / 12,198 newborn

Puskesmas
(primary health centers)

243

One PHC / 30,000 pop.

1 / 31,722 pop.

General practitioner in
Puskesmas

239

--

1/ 32,253 pop.

Puskesmas with bed

74

--

30% of all puskesmas

4 / district

1
2

Coverage

Rows bordered in red are below minimum standard

South Sumatra National

Total population (2005) 1

Total fertility rate / 1000 women

who have begun childbearing is almost half the national average (5.5%). Among all contraceptive users, most women choose injection (49%), implants
(18%), oral contraceptives (16%) or tubal ligation/
vasectomy (8%).

Puskesmas BEONC

56

(WHO minimum standard:


One / 125,000 pop.)

23% of all puskesmas


Average 4/district; 1 of 14
districts have none
1 / 137,652 pop.

Comprehensive Emergency Obsetric and Neonatal Care, 24 hour service.

The total fertility rate (2.3) and crude birth rate (23.6) are similar to the national average. The
modern contraceptive prevalence rate is also similar (57%) but the percentage of young women
Provincial Reproductive Health & MPS Profile of Indonesia

59

SOUTH SUMATRA
South Sumatra reports only 17 hospitals 9 public and 8 private. There are 18 Ob/Gyn specialists and 15 pediatricians working in hospitals, but staffing in public hospitals appears to be better
than in private hospitals.
All 9 public hospitals are certified as providers of Comprehensive Emergency Obstetric and Neonatal Care (CEONC) with only 9 of 14 districts reporting one; Musi Rawas, Banyuasin, Ogan
Ilir, Okut, Okus report none.
South Sumatra has 243 puskesmas (primary health centers) with a similar number of puskesmasbased general practitioners (239). Nearly 1 in 3 puskesmas (30%) has a bed for in-patient care.
The population covered by each puskesmas, on average, exceeds the recommendation of 1/30,000
slightly.

HEALTH PERSONNEL
%
Coverage
2001
2005
(minimum standard)
Change
Rows bordered in red are below minimum standard
OB/GYNs

25 1

18

28%

Pediatricians

35 1

15

57%

Primary health center general practitioners


(One GP / 30,000 pop.)

255 1

305

20%

Nurses trained in ANC

267

553

107%

Total midwives
(One / 3000 pop.)

2484 1

2896

17%

1 / 2662 population

Midwives living in the village


(One / village)

2080 1

1556

25%

56% of villages have


village midwife

Midwives with a kit

2484 1

1419

43%

1 / 5432 population

Midwives trained in APN

Not reported

182

--

6% midwives

Midwives trained in LSS

Not reported

--

--

Total TBA

5681

4754

16%

Trained TBA

4083

3002

26%

63% of all TBA

TBA with kit

3127 1

2259

28%

48% of all TBA

One immediate step would be to upgrade each puskesmas with a bed to BEONC level, focusing
first on districts with no BEONC or CEONC facility (see those highlighted above). The cost per
puskesmas team (3 persons) to be trained in BEONC is 9.3 million (3.1 per person).

Health Personnel
The total number of specialists in South Sumatra is small with only one Ob/Gyn for every 428,000
and one pediatrician for every 514,000 people. Specialists have also declined since 2001. The
coverage of GPs exceeds the recommended standard. Population coverage of midwives also
meets the recommended standard of 1/3000. Just more than half (56%) of all villages are reported to have a midwife living in the village, with significant decreases since 2001. Only 6% of
all midwives have received APN training and none are reported to have received LSS training.

Primary Health Care Indicators


1 / 25,274 population

Three districts (BGK, BLT, PKL) did not report this indicator. These 3 districts represent 3 of a total of 4 districts which
became Bangka Belitung province in 2002.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 56 puskesmas (23%) are reported to have received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO)
recommended standard for BEONC facilities is 1 for every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least four BEONC facilities for each district.
On average, the population coverage of BEONC facilities in South Sumatra is below the standard
of 1/125,000. An additional 18 BEONC facilities are needed to reach 4 per district; and an additional 25 to meet the recommendation of 1/125,000 population.

60

The distribution of them is not adequate too. One district has none (Prabamulih), and several
districts report only one or two, despite significant population size (Palembang, OKU).

The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.
One district (OKU) reported far fewer (20%) pregnancies, deliveries and newborn than expected,
and this districts reports were also inconsistent with the total number of events reported in 2004.
Therefore, 2004 reported events were used for Oku district in 2005 event totals (and denominators) reported in this profile. Assuming a crude birth rate in South Sumatra of 23.6 (BPS, 2000),
the corrected reported pregnancies are about 1% lower than the estimated pregnancies, and
corrected reported deliveries the same as estimated deliveries. The proportion of deliveries to
pregnancies, and newborn to deliveries is valid and consistent with the country overall, further
supporting the accuracy of the reported events.

DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported / estimated 1

Reported pregnancies

200,171

2.60% of total population

99.1

Reported deliveries

190,905

95.4% of reported pregnancies

99.9

Reported newborn

182,974

95.9% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.

Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Provincial Reproductive Health & MPS Profile of Indonesia

SOUTH SUMATRA
There has been no trend toward changing rates of antenatal coverage since
2001, but a steadily increasing trend in
SBA coverage from 65% in 2001 to 82%
in 2005.

Antenatal Care Coverage


More than 6 out of 7 (86%) pregnant women attended the first 4 antenatal visits in South Sumatra. Only 6% attended ANC1 but did not complete
all 4 visits. South Sumatra has exceeded the national target for antenatal care in 2007 (84%) and
is within reach of the 2010 target (95%).
The Indonesian Demographic Health Survey
(IDHS, 2002/3) describes the components of antenatal care provided in South Sumatra. More than 95% of women report having an abdominal
examination, more than 88% reported having their blood pressure and weight measured, and
80% received iron tablets. However, only 32% report being informed of signs of pregnancy complications and only 17% report giving a blood sample. Although reported antenatal attendance
is very high in South Sumatra, the above data suggest that the quality of care may be less than
optimal.
There is minimal variation in reported antenatal coverage by most districts, however, two districts,
Lb. Linggau and Okus, report lower rates of ANC1 (78% and 80%, respectively) and ANC4 (72%
and 76%, respectively) compared to the provincial average.

Skilled Birth Attendance


About 82% of all reported deliveries are attended
by a skilled health professional (SBA=skilled birth
attendant). While this coverage meets the recommended target for 2007 (82%), there are still over
34,000 women delivering without any skilled birth
attendant.
The IDHS estimated (2002/3) that more than
9% of women are attended by a doctor at delivery; 67% by a nurse midwife, and 23% by a
TBA, relative or other attendant. More than onethird (38%) delivered at a health facility
(mostly private), and 62% delivered at
home (IDHS).
There is minimal variation in reported
SBA coverage by most districts, however, three districts, Muba, Lb. Linggau and Okus, report lower rates of
SBA coverage (69%, 72% and 73% respectively) than the provincial average.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that 64% of all births are officially registered in South Sumatra, more than
the national average, but still low. About 85% of
all reported newborn attend the first neonatal visit
(KN1); data for the second neonatal visit was not
utilized for calculation of KN2 coverage since most
districts reported higher KN2 attendance than KN1
attendance. The IDHS found double the rates of
missing care altogether (32%) compared to that reported by the HIS in 2005 (15%).

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate
of pregnant women detected as at risk by the community, including cadres, TBAs or other lay

Provincial Reproductive Health & MPS Profile of Indonesia

61

SOUTH SUMATRA
persons (i.e. non-health professionals).
Indonesia adopted that 20% of all pregnant women will need medical attention
during pregnancy or delivery, or over
40,000 pregnant women in South Sumatra annually (20% of all pregnant women
reported).

recording causes of maternal deaths in order to more closely track progress toward
effective management of obstetric complication and identify potential interventions to
reduce maternal mortality.

Overall, only 16% of these total number


of women were detected as being at
risk by community members and 48%
were detected by a health provider (denominator adjusted, applicable to reporting districts only).
Less than 1% of all expected maternal complications (20% of pregnancies) were managed by the
health care system at primary or tertiary levels of care. The national target for obstetric complications management is 60% by 2007 and 80% by 2010. South Sumatra is below national expectations on this indicator.

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)
50
45
40
35
30
25
20
15
10
5
0

46
37
29

28
15

The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based on reported data, South Su2001
2002
2003
2004
2005
matra has a neonatal mortality rate of only
1.7 compared to a national estimate of 18 neonatal deaths per 1000 births (WHO, 2006). IDHS
2002/2003 also reported higher neonatal mortality rate (19/1000 births). Therefore, it is unlikely
that the South Sumatra data on neonatal mortality are accurate enough to utilize as an outcome
indicator.

Management of neonatal complications (estimated to be 25% of newborn born) appears to be


significantly lower. While the national target for 2007 is 60%, increasing to 80% in 2010, South
Sumatra reports managing less than 1% of all expected neonatal complications.

The ratio of early to late neonatal deaths is not consistent with international estimates, with less
than 2% of all reported neonatal deaths occurring before the first 7 days. This means that early
neonatal deaths are more often missed than late neonatal deaths, though all neonatal deaths appear to be under-reported. WHO estimates that three-quarters of all neonatal deaths in Indonesia
occur in the first week of life, suggesting the importance of improving quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g. resuscitation, infection prevention,
early detection and treatment, and management of low birth weight newborn).

Maternal and Neonatal Deaths

The reported stillbirth rate is 2.3 / 1000 estimated deliveries in South Sumatra compared to the
national estimate of 17.

There were 54 maternal deaths reported


in South Sumatra in 2005, about 1% of
all reported maternal deaths in Indonesia. The estimated maternal mortality
ratio (MMR) is very low at 29 / 100,000
live births. This is far smaller than national estimates (MMR=230, range 58
to 440, WHO/UNICEF/UNFPA, 2000
or MMR=307, IDHS, 2002/3) and suggests significant under-reporting.

Causes of Maternal Deaths, 2005


eclampsia
25%

infection
12%

other /
unknown
22%

bleeding
41%

to safe blood transfusion/fluid replacement). Wo

The predominant cause of maternal death in South Sumatra is bleeding, though eclampsia also
plays a significant role. Key interventions to reduce risk of hemorrhage should be emphasized
(iron deficiency anemia control, trained midwives, appropriate use of oxytocics in active management of 3rd stage as per national policy, access to safe blood transfusion/fluid replacement).
Women with signs or symptoms of hypertensive disorders of pregnancy should be treated properly and actively referred to specialist care at a hospital, since early delivery by c-section is the
most effective measure to prevent progression to eclampsia and death.
It should be noted that more than one-fifth (22%) of all maternal deaths are not attributed to any
immediate cause of death. More importance should be attached to correctly diagnosing and

62

Hospital Management of Maternal and Neonatal Complications


Number

% of Hospital
Cases

OB/GYN cases treated at hospital


(includes normal deliveries)

6864

--

Complicated OB/GYN cases treated


at hospital 2

3238

47.2

--

15

0.46

25.0% of reported maternal


deaths (60 in 2004) occured in
hospital

Hospital admissions due to abortion

1268

18.5

--

Caesarean sections

955

13.9

0.6% of all deliveries

HOSPITAL CASES

Case fatality rate 3

% Coverage
(reported pregnancies) 1
3.9% of all pregnancies

Denominators from 2004 data were pregnancies: 177,983; deliveries: 171,140.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Reported data from hospitals in South Sumatra indicate that nearly 4% of all deliveries occur in
hospital. Nearly one-half of these deliveries are classified as complicated.

Provincial Reproductive Health & MPS Profile of Indonesia

SOUTH SUMATRA
8. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

The case fatality rate for complications is


low at 0.5% and 25% of reported maternal
deaths occurred in hospital.

Data quality and reporting

Nearly 39% of all hospital admissions are


due to abortion, suggesting a high rate of
unsafe abortion practices in South Sumatra. Nearly 14% of all deliveries in hospital
are by caesarean section. The c-section
rate over all deliveries in the province is
low at less than 1% and suggests that
there are some women delivering outside of hospitals who would have had better outcomes if
delivered by c-section. Internationally, from 5-15% of women are expected to require delivery by
c-section for optimal maternal/neonatal outcome.

9. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.

Recommendations

BEONC UNMET NEED ACCORDING TO STANDARDS

Coverage of health personnel and service inputs

10. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
11. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

District

1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife. With currently high rates of
SBA coverage, the most important agenda for South Sumatra should be to aggressively upgrade the technical skills of those attendants and ensure adequate access to well-prepared
facilities.
4. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.

1
2
3
4
5
6
7
8
9
10
11
12
13
14

Total
population

OKU
OKI
M.Enim
Lahat
Musi Rawas
Muba
Palembang
Prabumulih
Pagar Alam
Lb. Linggau
Banyuasin
Ogan Ilir
Okut
Okus
TOTAL

1,216,838
656,694
608,010
570,760
456,288
451,701
1,300,963
126,172
120,211
166,006
690,422
349,168
632,739
362,562
7,708,534

#
Total Unmet
BEONC Need (MOH:
in 2005 4 / district)
2
7
6
7
8
9
1
0
1
1
3
5
4
2
56

2
0
0
0
0
0
3
4
3
3
1
0
0
2
18

Pop. /
BEONC
608,419
93,813
101,335
81,537
57,036
50,189
1,300,963
-120,211
166,006
230,141
69,834
158,185
181,281
137,652

WHO recomUnmet
mended covneed
erage
(WHO)
(1 / 125,000)
10
5
5
5
4
4
10
1
1
1
6
3
5
3
63

8
0
0
0
0
0
9
1
0
0
3
2
1
1
25

5. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
6. Improve management of obstetric and neonatal complications. Again, given high rates of
SBA coverage, community awareness of pregnancy risk, and active commitment to ensuring good referral systems could contribute significantly toward even safer deliveries.
7. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.

Provincial Reproductive Health & MPS Profile of Indonesia

63

SOUTH SUMATRA
COVERAGE OF MIDWIFE PERSONNEL
Total reported deliveries

District
1
2
3
4
5
6
7
8
9
10
11
12
13
14

OKU
OKI
M.Enim
Lahat
Musi Rawas
Muba
Palembang
Prabumulih
Pagar Alam
Lb. Linggau
Banyuasin
Ogan Ilir
Okut
Okus
TOTAL

Total LSS midwives

Total APN midwives

30,153 *
16,417
16,031
13,319
11,979
11,744
32,524
3,154
3,005
4,150
17,261
9,174
12,930
9,064

13
14
56
14
27
27
16
2
2
2
4
5
0
0

190,905

182
(1 / 1049 deliveries)

Not reported

* Pregnancies, deliveries and newborn from this district were taken from the 2004 HIS data report, as the 2005 events reports
were in obvious error, at only 20% of expected events.

South Sumatra

National Target

2001

2005 *

2007

2010

ANC1 (K1)

92

92

ANC4 (K4)

82

86

84

95

SBA deliveries

65

82

82

90

Postpartum / Neonatal visit (KN1)

89

85

83

90

13.4

15.8

Obstetric complications managed

Not reported

0.8

60

80

Neonatal complications managed

Not reported

0.8

60

80

Caesarian section rate (% of hospital deliveries)

17.4

13.9 *

Caesarian section rate (% of reported deliveries)

1.5

0.6 *

Hospital OB/GYN cases as % of all pregnancies

8.1

3.9 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

15

29

KEY INDICATORS AND NATIONAL TARGETS

Risk detection of pregnant women by community

* c-sections and hospital data from 2004.

64

Provincial Reproductive Health & MPS Profile of Indonesia

BENGKULU

he total population of Bengkulu is 1.7 million, accounting for less than 1% of the total population
in Indonesia, and only 3.6% of the population in
Sumatra. Bengkulu is divided into 9 districts (8
kabupaten + 1 kota [city]) with a total of 1233 villages.
The capital is Bengkulu city.

GEOGRAPHY

Total land area (km2)


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

19,795
9
8
1
99
1233

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

Bengkulu has a lower urban population (35%) and slightly higher poor population (21%) compared to the national
average. Adult female literacy is higher than the national rate at 91%.

Among all contraceptive users, most women choose injection (45%) or oral contraceptives (19%).
Other methods include implants (13%), IUD (9%), traditional methods (6%), tubal ligation/vasectomy (6%), or condoms (3%).

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

Bengkulu
1,700,055
35
21
91
82
Male: 64
Female: 67
2.13
398,490 3
3.0
25.4
13.8
64.0
8.0

National

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population,
using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

Bengkulu reports only 9 hospitals 7 public and


2 private in 2004 (not reported in 2005). Coverage of Comprehensive Emergency Obstetric
and Neonatal Care (CEONC) cannot be determined since these data were not reported for
2004 and 2005.

Contraceptive Methods Used


(IDHS 2002/3)
injection,
45%

pill, 19%

implant, 13%

IUD, 9%
permanent,

traditional

The total fertility rate (3.0) and crude birth rate (25.4) are slightly higher than the national average.
The modern contraceptive prevalence rate is also higher (64%), but the percentage of young
women who have begun childbearing is also higher than the national average (13.6%).

SOCIAL DEMOGRAPHY

Health Facilities

methods, 6%
condom, 3%
5%
Bengkulu has 117 puskesmas (primary health
centers) with a similar number of puskesmasbased general practitioners (115). Nearly 1 in 5 puskesmas (21%) has a bed for in-patient care. The
population covered by each puskesmas, on average meets the recommended standard.

2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

72

22

1 CEONC hospital / district


Not
Not
Hospitals with CEONC 1
reported reported (WHO minimum standard:
one / 500,000 pop.)
Not reNot reIn-hospital OBGYN
-ported
ported
Not reNot reIn-hospital pediatricians
-ported
ported
Puskesmas
117
One PHC / 30,000 pop.
(primary health centers)
General practitioner in
115
-Puskesmas
Puskesmas with bed
24
-4 / district
Puskesmas BEONC

(WHO minimum standard:


One / 125,000 pop.)

-----

1 / 14,530 pop.
1/ 14,783 pop.
21% of all puskesmas
4% of all puskesmas
Average <1/district; 5
of 9 districts have none
1 / 340,011 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.


2
This indicator was not reported in 2005, these are data from 2004.
1

Provincial Reproductive Health & MPS Profile of Indonesia

65

BENGKULU
Access to Basic Emergency Obstetric Care (BEONC or PONED)

Primary Health Care Indicators

Only five puskesmas (4%) are reported to have received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO)
recommended standard for BEONC facilities is 1 for every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least four BEONC facilities for each district.

The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in Bengkulu of 25.4 (BPS, 2000), the reported pregnancies are about
1% lower than the estimated pregnancies, and reported deliveries the same as estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries is valid and consistent
with the country overall, further supporting the accuracy of the reported events.

The majority of districts (5 out of 9) report no BEONC facility: Rejang Lebong, Muko-Muko,
Kepahyang, Kaur, Lebong. On average, the population coverage of BEONC facilities in Bengkulu is far below the standard of 1/125,000. An additional 31 BEONC facilities are needed to
reach 4 per district; and an additional 9 to meet the recommendation of 1/125,000 population.
One immediate step would be to upgrade each puskesmas with a bed to BEONC standards,
focusing first on districts with no BEONC or CEONC facility (see those highlighted above). The
cost per puskesmas team (3 persons) to be trained in BEONC is 9.3 million (3.1 per person).

Health Personnel
HEALTH PERSONNEL
%
2001
2005
Coverage
(minimum standard)
Change
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general
practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in LSS
Total TBA
Trained TBA
TBA with kit

Not reported
Not reported

81
51

Not reported

174

Not reported

Not reported

--

1245

1315 2

6%

935 3

611 2

35%

692 3
Not reported
Not reported
Not reported
Not reported
Not reported

328
10
0
1874
1044
234

53%
------

These data from 2004, not reported in 2005.


One district (Rejang Lebong) did not report this indicator.
3
One district (Kota Bengkulu) did not report this indicator.
1

---

--

1 / 9770 population

1 / 1293 population
50% of villages have
village midwife
1 / 5183 population
0.8% midwives
-56% of all TBA
12% of all TBA

The total number of specialists (last reported in 2004) in Bengkulu is small with less than one Ob/
Gyn for more than 210,000 population, and one pediatrician for more than 340,000 population.
The coverage of GPs meets the recommended standard. Population coverage of midwives also
meets the recommended standard of 1/3000. However, only 50% of all villages report having a
midwife living in the village, and this coverage has decreased 35% since 2001. Less than 1% of all
midwives have received APN training and none are reported to have received LSS training.

66

DENOMINATORS FOR KEY


INDICATORS
Reported pregnancies
Reported deliveries
Reported newborn

Number

47,360
45,208
43,054

2.79% of total population


95.5% of reported pregnancies
95.2% of reported deliveries

Ratio of reported
/ estimated 1
98.8
99.7
--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Antenatal Care Coverage


Among reported pregnancies, 80% of the womAntenatal Care Coverage 2005
en attended at least one antenatal visit (ANC1).
This drops to 74% coverage of 4 total antenatal
ANC1 & 4
74%
visits (ANC4). Nearly 9500 pregnant women
never accessed any antenatal care, and almost
3000 women who have accessed antenatal
ANC1 only
no ANC
20%
6%
care once do not obtain the minimum standard
of 4 antenatal visits. These women are either
not adhering to the recommended antenatal
schedule or are accessing ANC too late to reach 4 visits. Quality of care, community awareness,
and logistical accessibility factors likely account for these missed opportunities. Bengkulu is
below the national target for antenatal care in 2007 (84%).
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in Bengkulu. About 98% of women report having an abdominal examination,
92% report having their blood pressure measured, 84% have their weight measured and receive
iron tablets. However, only 34% report being informed of signs of pregnancy complications and
only 12% report giving a blood sample. The above data suggest that the quality of care may be
less than optimal.
There is minimal variation in reported antenatal coverage by most districts, however, one district,
Lebong, had lower rates of ANC1 (63%) and ANC4 (49%) compared to the provincial average.

Skilled Birth Attendance

Provincial Reproductive Health & MPS Profile of Indonesia

BENGKULU
About 70% of all reported deliveries are attended
by a skilled health professional (SBA=skilled birth
attendant). This leaves nearly 14,000 women delivering without any skilled birth attendant. The
national target for skilled birth attendance is 82%
by 2007 and 90% by 2010.
The IDHS estimated
(2002/3) that 7% of women
are attended by a doctor at
delivery; 61% by a midwife,
and 30% by a TBA, relative
or other attendant. Only
13% delivered at a health
facility and 85% delivered
at home (IDHS). This rate
of home delivery is among
the highest in the country.

Skilled Birth Attendant Coverage


2005
no SBA
30%

SBA
70%

Place of Delivery (IDHS, 2002/3)

Postpartum (Neonatal) Care Coverage


The IDHS estimates that 57% of all births are
officially registered in Bengkulu, more than the
national average, but still low. About 73% of all
reported newborn attend the first and second
neonatal visits (KN1, KN2); only 3% attend KN1
only. The IDHS found far lower rates of missing
care altogether (8%) compared to that reported
by the HIS in 2005 (24%).

Postpartum / Neonatal Care


Coverage 2005
KN1 &
KN2, 73%
no
postnatal /
neonatal
care, 24%

KN1 only,
3%

100.0%
80.0%

Birth Registration and Postnatal Care (IDHS, 2002/3)

60.0%
40.0%

100.0%

20.0%

80.0%

0.0%

There is minimal variation


in reported SBA coverage
by most districts, however, one
district, Lebong, had lower
rates of SBA coverage (53%)
than the provincial average.

public health private health


facility
facility

home

other /
missing

Bengkulu

5.0%

8.0%

85.0%

1.9%

Indonesia

9.2%

30.5%

59.0%

1.2%

60.0%
40.0%
20.0%
0.0%

Assistance During Delivery (IDHS, 2002/3)

birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

80.0%

Bengkulu

57.0%

88.3%

1.8%

1.6%

8.2%

60.0%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

40.0%
20.0%

There has been an inconsistent but increasing trend in


antenatal (K4) coverage since
2001 of about 5 percentage
points. SBA coverage has
also increased since 2001 by
about 10 percentage points.

0.0%

Ob/Gyn or
GP

midw ife or
nurse

TBA

relative or
other

nobody

Bengkulu

7.2%

61.4%

29.5%

1.0%

0.3%

Indonesia

11.0%

55.3%

31.5%

1.3%

1.1%

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005
100.0%
50.0%

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate
of pregnant women detected as at risk by the community, including cadres, TBAs or other lay
persons (i.e. non-health professionals). Indonesia adopted that 20% of all pregnant women will
need medical attention during pregnancy or delivery, or about 9,500 pregnant women in Bengkulu
annually (20% of all pregnant women reported).
Overall, only 12%of this total number
of women were detected as being at
risk by community members and 82%
were detected by a health provider
(denominator adjusted, applicable to
reporting districts only).

Pregnancy Risk Detection


and Management of Complications
100.0%
80.0%
60.0%
40.0%
20.0%

0.0%
k4

2001

2002

2003

2004

2005

68.3% 73.0% 79.2% 73.8% 73.9%

SBA 59.6% 64.5% 73.7% 71.8% 69.7%

Less than 12% of all expected maternal complications (20% of pregnancies) were managed by the health
care system at primary or tertiary
levels of care. The national target for
Provincial Reproductive Health & MPS Profile of Indonesia

0.0%

detected by
community

detected by
health provider

maternal
complications

denominator=20% reported
pregnancies

11.9%

82.1%

11.5%

denominator=all pregnant
w omen

2.4%

16.4%

2.3%

67

BENGKULU
obstetric complications management is 60% by 2007 and 80% by 2010. Bengkulu is below national expectations on this indicator.
Management of neonatal complications (estimated to be 25% of newborn born) appears to be
significantly lower. While the national target for 2007 is 60%, increasing to 80% in 2010, Bengkulu
reports managing less than 8% of all expected neonatal complications.

The ratio of early to late neonatal deaths is consistent with estimates for Indonesia. About 83%
of all neonatal deaths in Bengkulu occurred in the first 7 days of life suggesting the importance
of improving quality and access to pregnancy care, safer delivery and emergency neonatal care
(e.g. resuscitation, infection prevention, early detection and treatment of sepsis, and management of low birth weight newborn).

Maternal and Neonatal Deaths

The reported stillbirth rate is 3.6 / 1000 estimated deliveries in Bengkulu compared to the national
estimate of 17.

There were 26 maternal deaths reported in Bengkulu in 2005, less than


1% of all reported maternal deaths
in Indonesia. The estimated maternal mortality ratio (MMR) is low at 60
/ 100,000 live births. This is smaller
than national estimates (MMR=230,
range 58 to 440, WHO/UNICEF/
UNFPA, 2000 or MMR=307, IDHS,
2002/3) and suggests significant
under-reporting.

Causes of Maternal Deaths, 2005


other /
unknown
42%

bleeding
43%

eclampsia
15%

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)

The predominant cause of mater140


122
nal death in Bengkulu is bleeding,
120
though eclampsia also plays a sig100
81
77
nificant role. Key interventions to
80
60
60
reduce risk of hemorrhage should
41
40
be emphasized (iron deficiency
20
anemia control, trained midwives,
0
appropriate use of oxytocics in ac2001
2002
2003
2004
2005
tive management of 3rd stage as
per national policy, access to safe
blood transfusion/fluid replacement). Women with signs or symptoms of hypertensive disorders
of pregnancy should be treated properly and actively referred to specialist care at a hospital, since
early delivery by c-section is the most effective measure to prevent progression to eclampsia and
death.
It should be noted that 42% of all maternal deaths are not attributed to any immediate cause of
death. More importance should be attached to correctly diagnosing and recording causes of
maternal deaths in order to more closely track progress toward effective management of obstetric
complication and identify potential interventions to reduce maternal mortality.
The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based
on reported data, Bengkulu has a neonatal mortality rate of only 4.8 compared to a national estimate of 18 neonatal deaths per 1000 births (WHO, 2006). The IDHS 2002/2003 is also noted a
higher neonatal deaths (27/1000 births).Therefore, it is unlikely that the Bengkulu data on neonatal mortality are accurate enough to utilize as an outcome indicator.

68

Hospital Management of Maternal and Neonatal Complications


Reported data from hospitals in Bengkulu
indicate that nearly 4% of all deliveries occur in hospital. About one-half of these deliveries are classified as complicated.
The case fatality rate for complications is
very high at over 5% (WHO>1%) and more
than 100% of reported maternal deaths
occurred in hospital. This means that the
health information system under-counts
deaths through their databases.

Obstetric Complications at Hospital 2004


other /
unknown
43%

abortion
18%

bleeding
26%
eclampsia
8%

infection
5.0%

Number

% of Hospital
Cases

OB/GYN cases treated at hospital


(includes normal deliveries)

1711

--

Complicated OB/GYN cases treated


at hospital 2

848

49.6

--

HOSPITAL CASES

% Coverage
(reported pregnancies) 1
3.8% of all pregnancies

Case fatality rate 3

44

5.19

159% of reported maternal


deaths (only 17 reported
through HIS in 2004) occurred in
hospital

Hospital admissions due to abortion

151

8.8

--

Caesarean sections

292

17.1

0.7% of all deliveries

Denominators from 2004 data were pregnancies: 44,753; deliveries: 42,067.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Nearly 9% of all hospital admissions are due to abortion, a lower rate than most other provinces
in the country, but reminding that there are still unsafe abortion practices in Bengkulu. More than
17% of all deliveries in hospital are by caesarean section. The c-section rate over all deliveries in
the province is low at less than 1% and suggests that there are some women delivering outside
of hospitals who would have had better outcomes if delivered by c-section. Internationally, from

Provincial Reproductive Health & MPS Profile of Indonesia

BENGKULU
5-15% of women are expected to require delivery by c-section for optimal maternal/neonatal
outcome.

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Given rapid increase in private hospitals, investigate data quality and completeness at
private versus public hospitals to identify gaps or weaknesses (i.e. no private hospital reported CEONC certification, what proportion of obstetric cases are handled in private vs.
public ).

12. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
13. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.
BEONC UNMET NEED ACCORDING TO STANDARDS
Total UnWHO recomTotal
#
Unmet
met Need
Pop. / mended covDistrict
popula- BEONC
need
(MOH:
BEONC
erage
tion
in 2005
(WHO)
4 / district)
(1 / 125,000)
1 Kota Bengkulu

362,517

362,517

2 Bengkulu Selatan

142,882

142,882

3 Rejang Lebong

247,058

--

4 Bengkulu Utara

312,963

156,482

5 Muko - Muko

132,834

--

4. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.

6 Kepahyang

127,370

--

7 Seluma

160,560

160,560

8 Kaur

111,659

--

5. Investigate the reason behind low ANC1 coverage. Why do so many women never access
antenatal care? Investigate the reasons behind the difference between ANC4 and ANC1
rates of attendance. Who are these women entering the system but not being retained?
Why do they drop out?

9 Lebong

102,212

--

TOTAL 1,700,055

31

340,011

14

3. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.

6. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
7. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
8. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
9. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
10. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

COVERAGE OF MIDWIFE PERSONNEL


Total reported
Total LSS midDistrict
Total APN midwives
deliveries
wives
1 Kota Bengkulu
9182
2
0
2 Bengkulu Selatan
3668
1
0
3 Rejang Lebong
6430
1
0
4 Bengkulu Utara
9205
1
0
5 Muko - Muko
3543
1
0
6 Kepahyang
3397
1
0
7 Seluma
4269
1
0
8 Kaur
2966
1
0
9 Lebong
2548
1
0
10
TOTAL
45,208
0
(1 / 4521 deliveries)

Data quality and reporting


11. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.

Provincial Reproductive Health & MPS Profile of Indonesia

69

BENGKULU
KEY INDICATORS AND NATIONAL TARGETS

Bengkulu

National Target

2001

2005 *

2007

2010

ANC1 (K1)

75

80

ANC4 (K4)

68

74

84

95

SBA deliveries

60

70

82

90

Postpartum / Neonatal visit (KN1)

64

77

83

90

Risk detection of pregnant women by community

Not reported

11.9

Obstetric complications managed

Not reported

11.5

60

80

Neonatal complications managed

Not reported

Not reported

60

80

Caesarian section rate (% of hospital deliveries)

25.7

17.1 *

Caesarian section rate (% of reported deliveries)

1.1

0.7 *

Hospital OB/GYN cases as % of all pregnancies

4.0

3.8 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

81

60

* c-sections and hospital data from 2004.

70

Provincial Reproductive Health & MPS Profile of Indonesia

LAMPUNG

he total population of Lampung is 7 million,


accounting for 3% of the total population in
Indonesia, and nearly 15% of the population in Sumatra. Lampung is divided into 10
districts (8 kabupaten + 2 kota [cities]) with a total of
2193 villages. The capital is Bandar Lampung.

GEOGRAPHY

Total land area (km2)


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

37,735
10
8
2
180
2193

Source: Beberapa Indikator Penting Sosial-Ekono-

mi Indonesia, Edisi Juli 2006, BPS.


Lampung has a lower urban population (27%) and
slightly higher poor population (21%) compared to the
national average. Adult female literacy is higher than the national rate at 90%.

SOCIAL DEMOGRAPHY
Total population (2005)

Percent urban population (2005)


Percent poor population (2004)

Adult female literacy rate (2004) 2


Population density (km sq.; 2005)

Life expectancy at birth (2002) 2


Annual growth rate (2000-2005) 2

Lampung

National

6,983,699

220,659,431

27

48

21

17

90

87

206

116

Male: 64
Female: 68

Male: 64
Female: 68

1.61

1.34

1,639,700 3

51,732,453 4

2.7

2.6

21.9

22.0

8.4

10.4

Modern contraceptive prevalence (%) 6

58.9

56.7

Unmet need for contraception (%) 6

7.3

8.6

Women of reproductive age


Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing

From provincial health data reports.


2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

The total fertility rate (2.7) and crude birth rate (21.9) are similar to the national average. The
modern contraceptive prevalence rate is also similar (59%), but the percentage of young women
who have begun childbearing is slightly lower than the national average (8.4%). Among all contraceptive users, most women choose injection (51%) or oral contraceptives (22%). Other common methods include implants (12%) and IUD (7%).

Health Facilities
Lampung reports 21 hospitals; 10 public and 11 private. There are 32 Ob/Gyn specialists and 26 pediatricians which appear to staff all public and private
hospitals, on average.
Only 7 of the 10 public hospitals are certified as providers of Comprehensive Emergency Obstetric and
Neonatal Care (CEONC) with 4 of 10 districts reporting none; Kota Bandar Lampung, Lampung Tengah, Lampung Barat, and Way Kanan.
2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

10

11

Hospitals with CEONC 1

Not reported

In-hospital OBGYN

17

15

--

In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in
Puskesmas
Puskesmas with bed

15

11

--

1 / 5552 pregnant
women
1 / 6212 newborn

218

One PHC / 30,000 pop.

1 / 32,035 pop.

210

--

1/ 33,256 pop.

33

--

15% of all puskesmas


15% of all puskesmas

1 CEONC hospital / district


(WHO minimum standard:
one / 500,000 pop.)

4 / district
Puskesmas BEONC

33

(WHO minimum standard:


One / 125,000 pop.)

--

<1 / district
<1 / 500,000 pop.

Average 3/district;
all districts report at
least 1
1 / 211,627 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.

Lampung has 218 puskesmas (primary health centers) with a similar number of puskesmas-based

Provincial Reproductive Health & MPS Profile of Indonesia

71

LAMPUNG
general practitioners (210). Only 15% of all puskesmas have a bed for in-patient care. The population
covered by each puskesmas, on average, slightly exceeds the recommended standard.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 33 puskesmas (15%) are reported to have received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO)
recommended standard for BEONC facilities is 1 for every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least four BEONC facilities for each district.
All districts report at least one BEONC facility. But on average, the population coverage of
BEONC facilities in Lampung is far below the standard of 1/125,000. An additional 33 BEONC
facilities are needed to reach 4 per district; and an additional 29 to meet the recommendation of
1/125,000 population. The cost per puskesmas team (3 persons) to be trained in BEONC is 9.3
million (3.1 per person).

Health Personnel
HEALTH PERSONNEL
(minimum standard)

Coverage

2005

Rows bordered in red are below minimum standard


OB/GYNs

32

Pediatricians

26

Primary health center general practitioners


(One GP / 30,000 pop.)

440

Nurses trained in ANC

1 / 15,872 population

Not reported

Total midwives
(One / 3000 pop.)

1511

1 / 4622 population

Midwives living in the village


(One / village)

841

38% of villages have village midwife

Midwives with a kit

20 1

Not calculated due to under-reporting

Midwives trained in APN

29 2

Not calculated due to under-reporting

Midwives trained in LSS

--

Total TBA

Not reported

Trained TBA

Not reported

--

TBA with kit

Not reported

--

1
2

Only Kota Bandar and Lampung reported this indicator; remaining districts report zero.
Only Kota Bandar and Lampung Timur reported this indicator; remaining districts report zero.

The total number of specialists in Laumpung is small with less than one Ob/Gyn for every 200,000
and one pediatrician for nearly 300,000 population. Data from 2001 and 2002 were not reported
so changes over time cannot be evaluated.
The coverage of GPs meets the recommended standard. However, population coverage of mid-

72

wives does not meet the recommended standard of 1/3000. An additional 817 midwives would
be required in Lampung to meet the recommended standard. Only 38% of all villages report
having a midwife living in the village. Only 2 districts reported APN training, so the proportion of
midwives with this training could not be calculated. No midwives were reported to have received
LSS training.

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in Lampung of 21.9 (BPS, 2000), the reported pregnancies are about
5% higher than the estimated pregnancies, and reported deliveries are about 6% higher than estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries is valid
and consistent with the country overall, further supporting the accuracy of the reported events.
One possible explanation for the discrepancy between reported and estimated events is that the
crude birth rate is actually higher than 21.9, or the population may be higher than reported.
DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported /
estimated 1

Reported pregnancies

177,672

2.54% of total population

104.7

Reported deliveries

170,145

95.8% of reported pregnancies

106.0

Reported newborn

161,520

94.9% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Antenatal Care Coverage


Among reported pregnancies, 93% of the
women attended at least one antenatal visit
(ANC1). This drops to 85% coverage of 4 total antenatal visits (ANC4). While Lampung
has met the national target for antenatal care
in 2007 (84%), more than 12,000 pregnant
women never accessed any antenatal care,
and over 13,000 women who have accessed
antenatal care once do not obtain the minimum standard of 4 antenatal visits. These women are either not adhering to the recommended
antenatal schedule or are accessing ANC too late to reach 4 visits. Quality of care, community
awareness, and logistical accessibility factors likely account for these missed opportunities.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal

Provincial Reproductive Health & MPS Profile of Indonesia

LAMPUNG
care provided in Lampung. About 98% of women report having an abdominal examination, 88%
reported having their blood pressure measured, 92% have their weight measured and 81% receive
iron tablets. However, only 21% report being informed of signs of pregnancy complications or giving
a blood sample. The above data suggest that the quality of care may be less than optimal.
There is minimal variation in reported antenatal coverage by most districts.

Skilled Birth Attendance


Nearly 3 out of 5 (74%) of all reported deliveries are attended by a skilled health professional
(SBA=skilled birth attendant). This leaves nearly
45,000 women delivering without any skilled birth
attendant. The national target for skilled birth attendance is 82% by 2007 and 90% by 2010.
The IDHS estimated (2002/3) that only 9% of women are attended by a doctor at delivery;
53% by a nurse midwife, and 37% by a
TBA, relative or other attendant. Nearly
42% delivered at a health facility (mostly
private), with the remaining 58% delivering at home (IDHS).
There is minimal variation in reported SBA
coverage by most districts. There is only a
slight increasing trend in antenatal coverage and SBA attendance since 2002 (not
reported in 2001).

Postpartum (Neonatal) Care Coverage


The IDHS estimates that 58% of all births are officially registered in Lampung, more than the national
average, but still low. About 80% of all reported
newborn attend the first and second neonatal visits
(KN1, KN2); only 3% attend KN1 only. The IDHS
found far lower rates of missing care altogether
(4%) compared to that reported by the HIS in 2005
(17%).

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring
progress toward making pregnancy safer
is the rate of pregnant women detected as
at risk by the community, including cadres, TBAs or other lay persons (i.e. nonhealth professionals). Indonesia adopted
that 20% of all pregnant women will need
medical attention during pregnancy or delivery, or about 35,500 pregnant women in
Lampung annually (20% of all pregnant
women reported).
Overall, only 3% of these total number of women were detected as being at risk by community
members and 25% were detected by a health provider (denominator adjusted, applicable to reporting districts only).
Management of maternal or neonatal complications was not reported in Lampung data of 2004 or
2005. The national target for both indicators is 60% by 2007 and 80% by 2010.

Maternal and Neonatal Deaths


There were 84 maternal deaths reported in Lampung in 2005, 2% of all reported maternal deaths
in Indonesia. The estimated maternal mortality ratio (MMR) is low at 52 / 100,000 live births.
Provincial Reproductive Health & MPS Profile of Indonesia

73

LAMPUNG
This is far smaller than national estimates
(MMR=230, range 58 to 440, WHO/UNICEF/UNFPA, 2000 or MMR=307, IDHS,
2002/3) and suggests significant underreporting.
The predominant cause of maternal death
in Lampung is bleeding, though eclampsia
also plays a significant role. Key interventions to reduce risk of hemorrhage should
be emphasized (iron deficiency anemia
control, trained midwives, appropriate
use of oxytocics in active management of
3rd stage as per national policy, access to
safe blood transfusion/fluid replacement).
Women with signs or symptoms of hypertensive disorders of pregnancy should be
treated properly and actively referred to
specialist care at a hospital, since early
delivery by c-section is the most effective
measure to prevent progression to eclampsia and death.

The case fatality rate for complications was low at


over 0.3% (WHO>1%) but fewer than 5% of reported maternal deaths occurred in hospital.

Causes of Maternal Deaths, 2005


bleeding
52%

Nearly 18% of all hospital admissions are due to


abortion suggesting that there are unsafe abortion
practices in Lampung. More than 32% of all deliveries in hospital are by caesarean section. The
c-section rate over all deliveries in the province is
low at less than 1% and suggests that there are
some women delivering outside of hospitals who would have had better outcomes if delivered by
c-section. Internationally, from 5-15% of women are expected to require delivery by c-section for
optimal maternal/neonatal outcome.

other /
unknown 32%
eclampsia
15%
infection
1%

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)
(no data reported in 2001)

90
80
70
60
50
40
30
20
10
0

78
57

2001

2002

2003

52

2004

52

2005

% of Hospital
Cases

% Coverage
(reported pregnancies) 1

OB/GYN cases treated at hospital


(includes normal deliveries)

3483

--

2.0% of all pregnancies

Complicated OB/GYN cases treated


at hospital 2

1444

41.4

--

0.28

4.8% of reported maternal


deaths (84 in 2004) occurred
in hospital

Hospital admissions due to abortion

620

17.8

--

Caesarean sections

1119

32.1

0.7% of all deliveries

Case fatality rate 3

It should be noted that one-third (32%) of all maternal deaths are not attributed to any immediate cause of death. More importance should be attached to correctly diagnosing and recording
causes of maternal deaths in order to more closely track progress toward effective management
of obstetric complication and identify potential interventions to reduce maternal mortality.
The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based
on reported data, Lampung has a neonatal mortality rate of only 3.1 compared to a national
estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the
Lampung data on neonatal mortality are accurate enough to utilize as an outcome indicator.
The ratio of early to late neonatal deaths is consistent with estimates for Indonesia. About 89%
of all neonatal deaths in Lampung occurred in the first 7 days of life suggesting the importance
of improving quality and access to pregnancy care, safer delivery and emergency neonatal care
(e.g. resuscitation, infection prevention, early detection and treatment of sepsis, and management of low birth weight newborn).
The reported stillbirth rate is 2.8 / 1000 estimated deliveries in Lampung compared to the national
estimate of 17.

Hospital Management of Maternal and Neonatal Complications


Reported data from hospitals in Lampung indicate that 2% of all deliveries occur in hospital. Over
41% of these deliveries are classified as complicated.

74

Number

HOSPITAL CASES

Denominators from 2004 data were pregnancies: 177,672; deliveries: 170,145.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to csection). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Given rapid increase in private hospitals, investigate data quality and completeness at
private versus public hospitals to identify gaps or weaknesses (i.e. no private hospital reported CEONC certification, what proportion of obstetric cases are handled in private vs.
public ).
3. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.

Provincial Reproductive Health & MPS Profile of Indonesia

LAMPUNG
4. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.
5. Investigate the reason behind low ANC1 coverage. Why do so many women never access
antenatal care? Investigate the reasons behind the difference between ANC4 and ANC1
rates of attendance. Who are these women entering the system but not being retained?
Why do they drop out?
6. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
7. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
8. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
9. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
10. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


11. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
12. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.

BEONC UNMET NEED ACCORDING TO STANDARDS


Total UnWHO recTotal
#
Unmet
met Need Pop. / ommended
District
popula- BEONC
need
(MOH:
BEONC coverage
tion
in 2005
(WHO)
4 / district)
(1 / 125,000)
1
2
3
4
5
6
7
8
9
10

Kota Bandar Lampung


803,466
Lampung Selatan
1,207,091
Lampung Tengah
1,091,576
Lampung Utara
561,138
Lampung Barat
393,520
Tulang Bawang
743,945
Tanggamus
801,959
Way Kanan
360,404
Lampung Timur
895,515
Kota Metro
125,085
TOTAL 6,983,699

2
5
3
2
9
3
3
1
4
1
33

COVERAGE OF MIDWIFE PERSONNEL


Total reported
District
deliveries
1
2
3
4
5
6
7
8
9
10

Kota Bandar Lampung


Lampung Selatan
Lampung Tengah
Lampung Utara
Lampung Barat
Tulang Bawang
Tanggamus
Way Kanan
Lampung Timur
Kota Metro

13. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Provincial Reproductive Health & MPS Profile of Indonesia

TOTAL

19,144
28,931
26,374
13,940
9,403
17,766
19,787
8,828
22,964
3,008

170,145

2
0
1
2
0
1
1
3
0
3
13

401,733
241,418
363,859
280,569
43,724
247,982
267,320
360,404
223,879
125,085
211,627

Total APN midwives


20
0
0
0
0
0
0
0
9
0
29
(coverage not calculated due to under-reporting)

6
10
9
5
3
6
6
3
7
1
56

Total LSS midwives

4
5
6
3
0
3
3
2
3
0
29

0
0
0
0
0
0
0
0
0
0
0

75

LAMPUNG
KEY INDICATORS AND NATIONAL TARGETS
ANC1 (K1)

Lampung
2002
(no data
2005 *
reported in
2001)

National Target
2007

2010

88

93

ANC4 (K4)

81

85

84

95

SBA deliveries

70

74

82

90

Postpartum / Neonatal visit (KN1)

89

83

83

90

Risk detection of pregnant women by community Not reported

3.0

Obstetric complications managed

Not reported Not reported

60

80

Neonatal complications managed

Not reported Not reported

60

80

Caesarian section rate (% of hospital deliveries)

32.9

32.1 *

Caesarian section rate (% of reported deliveries)

1.1

0.7 *

Hospital OB/GYN cases as % of all pregnancies

3.1

2.0 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

78

52

* c-sections and hospital data from 2004.

76

Provincial Reproductive Health & MPS Profile of Indonesia

BANGKA
BELITUNG

he total population of Bangka Belitung is


1 million, accounting for less than 0.5% of
the total population in Indonesia, and only
2% of the population in Sumatra. Bangka
Belitung is divided into 7 districts (6 kabupaten + 1
kota [city]) with a total of 321 villages.

GEOGRAPHY

Total land area (km )


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)
2

16,424
7
6
1
36
321

Source: Beberapa Indikator Penting Sosial-Ekonomi

Indonesia, Edisi Juli 2006, BPS.


Bangka Belitung is comprised mainly of two islands
northeast of South Sumatra, Bangka and Belitung.
The capital is Pangkal Pinang. The province became independent from South Sumatra in 2000.
The earliest health information system (HIS) report submitted separately for Bangka Belitung was
in 2002.

SOCIAL DEMOGRAPHY
Total population (2005)

Percent urban population (2005)

Percent poor population (2004) 2


Adult female literacy rate (2004)

Population density (km sq.; 2005)


Life expectancy at birth (2002)

Annual growth rate (2000-2005) 2


Women of reproductive age
Total fertility rate / 1000 women

Bangka Belitung

National

1,001,4443

220,659,431

48

48

17

91

87

60

116

Male: 64
Female: 67

Male: 64
Female: 68

1.54

1.34

234,740
6

Crude birth rate / 1000 pop. (2000)

Percentage of women 15-19 who have begun childbearing


Modern contraceptive prevalence (%)
Unmet need for contraception (%) 6

51,732,453 4

2.4

2.6

23.6

22.0

5.8

10.4

63.3

56.7

5.6

8.6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1
2

Bangka Belitung has a similar urban population


(48%) and much lower poor population (9%)
compared to the national average. Adult female
literacy is higher than the national rate at 91%.
The total fertility rate (2.4) and crude birth rate
(23.6) are similar to the national average. The
modern contraceptive prevalence rate is higher
(63%) and the percentage of young women who
have begun childbearing is lower than the national average (5.8%). Among all contraceptive users, most women choose oral contraceptives
(42%) or injection (41%). Other methods include implants (7%), tubal ligation/vasectomy (3%),
traditional methods (3%), IUD (2%) or condoms (2%).

Health Facilities
Bangka Belitung reports only 10 hospitals 3 public and 7 private. The few public hospitals likely
have specialists in both Ob/Gyn and pediatrics, but it is not likely that all private hospitals have.
All 3 public hospitals are certified as providers of Comprehensive Emergency Obstetric and
Neonatal Care (CEONC) with only 3 of 7 districts having one; Bangka Tengah, Bangka Barat,
Bangka Selatan and Belitung Timur report none.
Bangka Belitung has 47 puskesmas (primary health centers) with a similar number of puskesmasbased general practitioners (45). More than 1 in 4 puskesmas (28%) has a bed for in-patient care.
The population covered by each puskesmas, on average, meets the recommended standard.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 3 puskesmas (6%) are reported to have received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO) recommended standard for BEONC facilities is 1 for every 125,000 people. Indonesia has adopted this
indicator, but translated it to mean at least four BEONC facilities for each district.
Only two districts have a BEONC facility; the remaining five districts report none. On average, the

Provincial Reproductive Health & MPS Profile of Indonesia

77

BANGKA BELITUNG
HEALTH FACILITIES

2005
Indonesia minimum
standard
Public Private

Coverage

Rows bordered in red are below minimum standard


Total hospitals (general)

-1 CEONC hospital /
district

Hospitals with CEONC 1

Not reported

In-hospital OBGYN

--

1 / 3888 pregnant women

In-hospital pediatricians

--

1 / 4145 newborn

(WHO minimum standard:


one / 500,000 pop.)

<1 / district
>1 / 500,000 pop.

Puskesmas
(primary health centers)

47

One PHC / 30,000 pop.

1 / 21,307 pop.

General practitioner in
Puskesmas

45

--

1/ 22,254 pop.

Puskesmas with bed

13

--

28% of all puskesmas


6% of all puskesmas

4 / district
Puskesmas BEONC

(WHO minimum standard:


One / 125,000 pop.)

Average <1/district; 5 of
7 districts have none
1 / 333,814 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.

HEALTH PERSONNEL
2002
2005
% Change
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general
practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in LSS
Total TBA
Trained TBA
TBA with kit

78

Not reported
Not reported

7
5

---

Not reported

77

--

Not reported Not reported


937

348

1 / 13,006 population

- 63%

811

196

76%

Not reported
Not reported
Not reported
Not reported
Not reported
Not reported

143
115
22
499
72
204

-------

1 / 2878 population
61% of villages have
village midwife
1 / 7003 population
33% midwives
-14% of all TBA
41% of all TBA

population coverage of BEONC facilities in Bangka Belitung is very poor at only 1 for more than
300,000 people. An additional 25 BEONC facilities are needed to reach 4 per district. But given
the relatively small population size of Bangka Belitung, an additional 6 BEONC facilities would
meet the recommended standard of 1 / 125,000.
One immediate step would be to upgrade each puskesmas with a bed to BEONC level, focusing
first on districts with no BEONC or CEONC facility (Bangka Tengah, Bangka Selatan, Belitung
Timur). The cost per puskesmas team (3 persons) to be trained in BEONC is 9.3 million (3.1 per
person).

Health Personnel
The total number of specialists in Bangka Belitung is small, but the coverage of GPs meets the
recommended standard. Population coverage of midwives also meets the recommended standard of 1/3000, though it appears to have decreased significantly since 2001. Only 61% of all
villages report having a midwife living in the village, with significant decreases since 2001. Onethird of all midwives have received APN training, but very few (6%) are reported to have received
LSS training.

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in Bangka Belitung of 23.6 (BPS, 2000), the reported pregnancies are
about 4% higher than the estimated pregnancies, and reported deliveries are 5% higher than estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries is valid
and consistent with the country overall, further supporting the accuracy of the reported events.
The likely explanation for the small discrepancy is that the crude birth rate is actually higher than
23.6, or the population is higher than reported.

DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported /
estimated 1

Reported pregnancies

27,219

2.72% of total population

103.8

Reported deliveries

25,977

94.5% of reported pregnancies

104.7

Reported newborn

24,871

95.7% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Provincial Reproductive Health & MPS Profile of Indonesia

BANGKA BELITUNG
delivered at a health facility (mostly
private), and 65% delivered at home
(IDHS). These data are not entirely
consistent with reported high rates of
SBA coverage. One explanation is
seen in the consistent trend observed
showing increasing coverage of antenatal care and SBA in Bangka Belitung since 2002 (data not reported for
2001).

Antenatal Care Coverage


More than 9 out of 10 (91%) pregnant women
attended the recommended 4 antenatal visits in
Bangka Belitung. Only 2% attended ANC1 but
did not complete all 4 visits. Bangka Belitung has
exceeded the national target antenatal care in
2007 (84%) and is within reach of the 2010 target
(95%).
The Indonesian Demographic Health Survey
(IDHS, 2002/3) describes the components of antenatal care provided in Bangka Belitung. More
than 97% of women report having an abdominal examination, more than 88% reported having
their blood pressure and weight measured. However, only 66% received iron tablets, 28% report
being informed of signs of pregnancy complications and only 41% gave a blood sample. Although
reported antenatal attendance is very high in Bangka Belitung, the above data suggest that the
quality of care may be less than optimal.
There is minimal variation in reported antenatal coverage by most districts, however, two districts,
Belitung and Belitung Timur, report lower rates of ANC4 (77% and 80%, respectively) compared to
the provincial average.

There is minimal variation in reported SBA


coverage by most districts, however, two
districts, Bangka Selatan and Belitung
Timur, report lower rates of SBA coverage (72% and 75% respectively) than the
provincial average.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that 65% of all births are officially registered in Bangka Belitung, more than the
national average, but still low. About 92% of all reported newborn attend the first neonatal visit (KN1);
data for the second neonatal visit was not reported. The IDHS found far lower rates of postpartum/
neonatal care attendance, and higher rates of missing care altogether (39%).

Skilled Birth Attendance


About 84% of all reported deliveries are attended
by a skilled health professional (SBA=skilled birth
attendant). Although this coverage meets the recommended target for 2007 (82%), there are still
over 4000 women delivering without any skilled
birth attendant.
The IDHS estimated (2002/3) that fewer than 4%
of women are attended by a doctor at delivery;
63% by a nurse midwife, and 31% by a TBA, relative or other attendant. About one-third (33%)

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate
of pregnant women detected as at risk by the community, including cadres, TBAs or other lay
persons (i.e. non-health professionals). Indonesia adopted that about 20% of all pregnant women
will need medical attention during pregnancy or delivery, or over 5000 pregnant women in Bangka
Belitung annually (20% of all pregnant women reported).

Provincial Reproductive Health & MPS Profile of Indonesia

79

BANGKA BELITUNG
Overall, only 27% of this total number of
women were detected as being at risk by
community members and 23% were detected
by a health provider.
Only 13% of all expected maternal complications (20% of pregnancies) were managed
by the health care system at primary or tertiary levels of care. The national target for
obstetric complications management is 60%
by 2007 and 80% by 2010. Bangka Belitung is below national expectations on this indicator.
Management of neonatal complications (estimated to be 25% of newborn born) appears to be
significantly lower. While the national target for 2007 is 60%, increasing to 80% in 2010, Bangka
Belitung reports managing about 4% of all expected neonatal complications.

There were 30 maternal deaths reported in Bangka Belitung in 2005, less than 1% of all reported
maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 121 / 100,000 live
births. This is smaller than national estimates (MMR=230, range 58 to 440, WHO/UNICEF/UNFPA, 2000 or MMR=307, IDHS, 2002/3) and
suggests under-reporting.
Causes of Maternal Deaths, 2005

The reported stillbirth rate is 3.5 / 1000 estimated deliveries in Bangka Belitung compared to the
national estimate of 17.

100

117

86

80
60
40
20

781

--

487

62.4

116
148

14.9
19.0

% Coverage
(reported pregnancies) 1
3.0% of all pregnancies
-0% of reported maternal deaths
(18 in 2004) occurred in hospital
-0.6% of all deliveries

Reported data from hospitals in Bangka Belitung indicate that about 3% of all deliveries occur in
hospital. Nearly 2/3 of these deliveries are classified as complicated.

121
97

% of Hospital
Cases

Denominators from 2004 data were pregnancies: 26,131; deliveries: 24,508.


Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.

(Babel districts in Sumsel did not report maternal


deaths in 2001)
120

Case fatality rate 3

Number

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)

140

OB/GYN cases treated at hospital (includes normal deliveries)


Complicated OB/GYN cases treated at
hospital 2

eclampsia
27%

infection
10%

HOSPITAL CASES

Hospital admissions due to abortion


Caesarean sections

bleeding
27%

other /
unknown
36%

0
It should be noted that more than one-third
2001
2002
2003
2004
2005
(36%) of all maternal deaths are not attributed to any immediate cause of death. More
importance should be attached to correctly diagnosing and recording causes of maternal deaths
in order to more closely track progress toward effective management of obstetric complication
and identify potential interventions to reduce maternal mortality.

80

The ratio of early to late neonatal deaths is consistent with estimates for Indonesia. More than
65% of all neonatal deaths in Bangka Belitung occurred in the first 7 days of life suggesting the
importance of improving quality and access to pregnancy care, safer delivery and emergency
neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis,
and management of low birth weight newborn).

Hospital Management of Maternal and Neonatal Complications

Maternal and Neonatal Deaths

The predominant causes of maternal death in


Bangka Belitung are bleeding and eclampsia.
Key interventions to reduce risk of hemorrhage should be emphasized (iron deficiency
anemia control, trained midwives, appropriate use of oxytocics in active management of
3rd stage as per national policy, access to safe
blood transfusion/fluid replacement). Women
with signs or symptoms of hypertensive disorders of pregnancy should be treated properly and actively referred to specialist care at
a hospital, since early delivery by c-section
is the most effective measure to prevent progression to eclampsia and death.

The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based
on reported data, Bangka Belitung has a neonatal mortality rate of only 4.2 compared to a national
estimate of 18 neonatal deaths per 1000 births (WHO, 2006). The IDHS 2002/2003 is also reported a higher neonatal deaths (28/1000 biths). Therefore, it is unlikely that the Bangka Belitung
data on neonatal mortality are accurate enough to utilize as an outcome indicator.

The case fatality rate for complications cannot be estimated because zero deaths were reported
in the latest data set (2004).
Nearly 15% of all hospital admissions are due to
abortion, suggesting a high rate of unsafe abortion
practices in Bangka Belitung. More than 19% of
all deliveries in hospital are by caesarean section.
The c-section rate over all deliveries in the province
is low at less than 1% and suggests that there are
women delivering outside of hospitals who would
have had better outcomes if delivered by c-section.
Internationally, from 5-15% of women are expected

Provincial Reproductive Health & MPS Profile of Indonesia

BANGKA BELITUNG
to require delivery by c-section for optimal maternal/neonatal outcome.

BEONC UNMET NEED ACCORDING TO STANDARDS

Recommendations

WHO recTotal
Total Unmet
Unmet
# BEONC
Pop. / ommended
populaNeed (MOH:
need
in 2005
BEONC coverage
tion
4 / district)
(WHO)
(1 / 125,000)

District

Coverage of health personnel and service inputs


1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife. With currently high rates of
SBA coverage, the most important agenda for Bangka Belitung should be to aggressively
upgrade the technical skills of those attendants and ensure adequate access to well-prepared facilities.
4. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
5. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
6. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.

1 Bangka

229,707

--

2 Bangka Tengah

128,907

--

3 Bangka Barat

137,481

68,741

4 Bangka Selatan

148,015

--

5 Belitung

134,230

--

6 Belitung Timur

87,481

--

7 Pangkal Pinang

135,622

135,622

1,001,443

25

338,814

TOTAL

COVERAGE OF MIDWIFE PERSONNEL


Total reported
District
Total APN midwives
deliveries

Total LSS midwives

1 Bangka

5,860

22

2
3
4
5
6
7

Bangka Tengah

3,469

20

Bangka Barat

3,753

13

Bangka Selatan

4,043

12

Belitung

3,383

25

Belitung Timur

2,313

14

Pangkal Pinang

3,156

25,977

115
(1 / 226 deliveries)

22
1 / 1181 deliveries)

TOTAL

7. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


8. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
9. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
10. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Provincial Reproductive Health & MPS Profile of Indonesia

81

BANGKA BELITUNG
KEY INDICATORS AND NATIONAL TARGETS

Bangka Belitung

National Target

2002 *

2005 **

2007

2010

ANC1 (K1)

94

93

ANC4 (K4)

85

91

84

95

SBA deliveries

79

84

82

90

Postpartum / Neonatal visit (KN1)

88

92

83

90

Risk detection of pregnant women by community

Not reported

27.2

Obstetric complications managed

Not reported

13.2

60

80

Neonatal complications managed

Not reported

4.3

60

80

Caesarian section rate (% of hospital deliveries)

Not reported

19.0 **

Caesarian section rate (% of reported deliveries)

Not reported

0.6 **

Hospital OB/GYN cases as % of all pregnancies

Not reported

3.0 **

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

117

121

* Bangka Belitung first submitted separate HIS data in 2002.


** c-sections and hospital data from 2004.

82

Provincial Reproductive Health & MPS Profile of Indonesia

KEPRI
ISLANDS

he total population of Kepri is 2.3 million, accounting for 1% of the total population in Indonesia, and nearly 5% of the population in Sumatra. Kepri is divided into 6 districts (4 kabupaten
+ 2 kota [cities]) with a total of 245 villages. The capital
is Tanjung Pinang. The three most populated islands of
Kepri are Bintan, Batam and Karimun. Natuna island is
the largest by size, but not densely populated.

GEOGRAPHY

Total land area (km2)


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

8,084
6
4
2
42
245

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

Kepri Islands were made into a separate province (from


the Riau province) in 2004. The first separate health information system data report was in
2004. Much of the data reported here for Kepri from the IDHS or the BPS still includes the Riau
province.
SOCIAL DEMOGRAPHY

Total population (2005)


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
1

Life expectancy at birth (2002) 2


Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

KEPRI *

2,354,433
50
12
96
65
Male: 66
Female: 70
4.30
551,880 3
3.2
24.8
8.5
55.7
10.4

National

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

* All statistics except for population are not reported separately by BPS for Kepri. Therefore, they are from Riau which included
Kepri districts until the HIS report of 2004.
1
From provincial health data reports. The total population might be over-reported since the population in 2004 was only 1.3
million.
2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000.
6
IDHS 2002/3.

Data from Riau show a similar urban population (50%) and lower poor population (12%) com-

pared to the national average. Adult female literacy


is higher than the national rate at 96%. These data
are not available separately for Kepri, however.
Riau data show a total fertility rate (3.2) and crude
birth rate (24.8) similar to the national average. The
modern contraceptive prevalence rate is also similar (56%) and the percentage of young women who
have begun childbearing is slightly lower than the
national average (8.5%). Among all contraceptive users in Riau/ Kepri, most women choose
injection (52%) or oral contraceptives (31%). Other methods include IUD (5%), implants (4%) or
traditional methods (4%).

Health Facilities
2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)


Hospitals with CEONC 1

Not reported

--

CEONC hospital/district
Not reNot reported (WHO minimum standard: -ported
one / 500,000 pop.)

In-hospital OBGYN

10

Not reported --

1 / 3789 pregnant women

In-hospital pediatricians

Not reported --

1 / 6893 newborn

Puskesmas
(primary health centers)

39

One PHC / 30,000 pop.

1 / 60,370 pop.

General practitioner in
Puskesmas

39

--

1 / 60,370 pop.

Puskesmas with bed

14

--

36% of all puskesmas

20% of all puskesmas


4 / district
Average 1.3/district; 4/6
(WHO minimum standard:
districts have none
One / 125,000 pop.)
1 / 294,304 pop.

Puskesmas BEONC
1

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.

Kepri reports only 3 public hospitals; the number of private hospitals was not reported. There are

Provincial Reproductive Health & MPS Profile of Indonesia

83

KEPRI ISLANDS
at least 10 OB/Gyn specialists and at least 5 pediatricians working in hospitals. These may be
higher since private hospital data was not reported.

The total number of specialists in Kepri was not reported. Coverage with GPs is just barely below
the recommended standard with 1/30,600 population.

The number of hospitals with certification to provide Comprehensive Emergency Obstetric and
Neonatal Care (CEONC) also was not reported.

Population coverage of midwives is far below the standard at fewer than half the midwives recommended. An additional 477 midwives would be needed. Only 51% of all villages report having
a midwife living in the village. Midwives who have received APN training or PGDON training are
not reported, or are zero.

Kepri has 39 puskesmas (primary health centers) with the same number of puskesmas-based general
practitioners. More than 1 in 3 puskesmas (36%) has a bed for in-patient care. The population covered by each puskesmas, on average, is twice the recommended standard of 1/30,000.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 8 puskesmas (20%) are reported to have received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC); half of the districts (Batam, Tanjung Pinang and
Lingga) report none. The current World Health Organization (WHO) recommended standard for
BEONC facilities is 1 for every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least four BEONC facilities for each district.
On average, more than twice the population is supported by each BEONC than recommended.
For every district to have 4 BEONC, and additional 17 would be required. According to population size, the total recommended number of BEONC facilities is 20, and an additional 15 are
recommended.
One immediate step would be to verify the BEONC coverage data reported here, then identify
districts that have puskesmas with beds but are not yet at BEONC level. Ideally, districts that
are currently under-served by BEONC and CEONC facilities will be made a priority (any district
outside of Kepri; Batam, Karimun and Tanjung Pinang are the most populated). The cost per
puskesmas team (3 persons) to be trained in BEONC is 9.3 million (3.1 per person).

Health Personnel
HEALTH PERSONNEL
%
2001
2005
Coverage
(minimum standard)
Change
Rows bordered in red are below minimum standard
Ob/Gyns
Pediatricians
Primary health center general practitioners (One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives (One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in LSS
Total TBA, trained TBA, TBA with kit
1

One district (Lingga) did not report.

84

Not reported Not reported


Not reported Not reported

---

Not reported

--

77 1

Not reported Not reported


372
308
186

126

186
76
Not reported
0
Not reported
0
Not reported Not reported

- 17%
32%
59%
----

1 / 30,577 population
1 / 7644 population
51% of villages have
village midwife
1 / 30,979 population
---

(Note: A possible error in reported population for the Kepri district was identified but the total
reported population was not adjusted due to lack of BPS data on Kepri as a separate province.
The total population of the Kepri province as reported on Wikipedia was only 1.2 million; the Kepri
district likely over-reported their population in the HIS data. Thus, if the population is about 1 million less than reported, the total number of midwives needed would be less than 100).

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.
Assuming a crude birth rate in Kepri of 24.8 (BPS, 2000 for Riau which included Kepri at that
time), the reported pregnancies and deliveries are each about 5% higher than the estimated
pregnancies and deliveries, respectively. However, the proportion of deliveries to pregnancies,
and newborn to deliveries is valid and consistent with the country overall, suggesting that the reported events are reasonably accurate. The likely explanation for the small discrepancy between
reported and estimated events is that the crude birth rate may be higher than 24.8, or the population may be higher than estimated.
DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported /
estimated 1

Reported pregnancies

37,889

2.90% of total population 2

105.3

Reported deliveries

35,931

94.8% of reported pregnancies

105.4

Reported newborn

34,463

95.9% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be lower than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be higher than estimated, or there is under-reporting of events.
2
One district, Kepri, was not included in the numerator or denominator of this calculation due to the questionable data on
reported population in this district.
1

Antenatal Care Coverage


Among reported pregnancies, 98% of the women attended at least one antenatal visit (ANC1).
This drops to 84% coverage of 4 total antenatal visits (ANC4), which meets the 2007 target. Although ANC1 coverage is very good, the difference between ANC4 and ANC1 shows that nearly

Provincial Reproductive Health & MPS Profile of Indonesia

KEPRI ISLANDS
5500 women who have accessed antenatal care once do not obtain the minimum standard of 4
antenatal visits. These women are either not adhering to the recommended antenatal schedule
or are accessing ANC too late to reach 4 visits. Quality of care, community awareness, and
logistical accessibility factors likely account for these missed opportunities. Fewer than 1000
pregnant women never accessed any antenatal care in Kepri.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in Riau, which included Kepri at that time. More than 94% of women report
having an abdominal examination; about 91% reported having their blood pressure taken and
80% report having their weight measured. However, only 71% received iron tablets, 28% were
informed of signs of pregnancy complications and 36% gave a blood sample. Although reported
antenatal attendance is relatively high in Riau/Kepri, the above data suggest that the quality of
care may be less than optimal.
There is minimal variation in reported antenatal coverage by most districts, however, one district,
Kepri, reported low rates of ANC1 and ANC4 (61% and 56% respectively) compared to the provincial
average.

Antenatal coverage and SBA attendance


since 2001 show consistent trends toward
increasing coverage of both indicators by
about 13% between 2001 2005.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that only 65% of all births are officially registered in Riau/Kepri, higher than
the national average, but still low. More than 4 out of 5 (82%) of all reported newborn attend the
first and second neonatal visits (KN1, KN2) and 4% attend KN1 only. The IDHS found similar
rates of early postpartum/neonatal care attendance, but slightly higher rates of missing care altogether (21%).

Skilled Birth Attendance


About 81% of all reported deliveries are attended by a skilled health professional (SBA=skilled
birth attendant), which is very close to the 2007 national target of 82%. However, there would still
be nearly 7000 women delivering without any skilled birth attendant.
For Riau/Kepri, the IDHS estimated (2002/3) that nearly 12% of women are attended by a doctor at delivery; 62% by a nurse midwife, and 23% by a TBA, relative or other attendant. More
than one-third (37%) delivered at a health facility (mostly private), and 60% delivered at home
(IDHS).

There is minimal variation in reported SBA


coverage by most districts, however, two
districts, Kepri and Natuna, reported lower rates of SBA coverage (55% and 57%
respectively) than the provincial average.

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring
progress toward making pregnancy safer is
the rate of pregnant women detected as at
risk by the community, including cadres,
TBAs or other lay persons (i.e. non-health
professionals). Indonesia adopted that
20% of all pregnant women will need medical attention during pregnancy or delivery,
or more than 7500 pregnant women in Kepri annually (20% of all pregnant women
reported).
Overall, only 21% of this total number of women were detected as being at risk by community
members and 74% were detected by a health provider (denominator adjusted, applicable to reporting districts only).
Less than 27% of all expected complications (20% of pregnancies for Indonesia) were managed

Provincial Reproductive Health & MPS Profile of Indonesia

85

KEPRI ISLANDS
by the health care system at primary or tertiary levels of care. The national target for obstetric
complications management is 60% by 2007 and 80% by 2010. Kepri is below national expectations on this indicator.

proving quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g.
resuscitation, infection prevention, early detection and treatment of sepsis, and management of
low birth weight newborn).

Management of neonatal complications (estimated to be 25% of newborn born) appears to be


significantly lower. While the national target for 2007 is 60%, increasing to 80% in 2010, Kepri
reports managing 11% of all expected neonatal complications.

The reported stillbirth rate is 11.8 / 1000 estimated deliveries in Kepri compared to the national
estimate of 17.

Hospital Management of Maternal and Neonatal Complications

Maternal and Neonatal Deaths


There were 88 maternal deaths reported
in Kepri in 2005, more than 2% of all reported maternal deaths in Indonesia. The
estimated maternal mortality ratio (MMR) is
relatively high at 255 / 100,000 live births.
This is within the range of national estimates
(MMR=230, range 58 to 440, WHO/UNICEF/
UNFPA, 2000 or MMR=307, IDHS, 2002/3)
and is among the highest reported MMRs in
Indonesia.

HOSPITAL CASES
Causes of Maternal Deaths, 2005
infection
2%

other /
unknown
28%
eclampsia
44%

bleeding
26%

The predominant causes of maternal death in


(denominator adjusted for Kepri districts counted in
Riau Province prior to 2004)
Kepri are eclampsia and bleeding. Women
300
255
250
with signs or symptoms of hypertensive dis190
200
orders of pregnancy should be treated prop129
150
121
erly and actively referred to specialist care at
100
a hospital, since early delivery by c-section
32
50
is the most effective measure to prevent pro0
2001
2002
2003
2004
2005
gression to eclampsia and death. Key interventions to reduce risk of hemorrhage should
be emphasized (iron deficiency anemia control, trained midwives, appropriate use of oxytocics in active management of 3rd stage as per
national policy, access to safe blood transfusion/fluid replacement).
It should be noted that more than one-quarter of all maternal deaths are not attributed to any cause
of death. More importance should be attached to correctly diagnosing and recording causes of
maternal deaths in order to more closely track progress toward effective management of obstetric
complication and identify potential interventions to reduce maternal mortality.
Reported stillbirths and neonatal deaths are very low, indicating substantial under-reporting.
Based on reported data, Kepri has a neonatal mortality rate of only 7.2 compared to a national
estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the
Kepri data on neonatal mortality are accurate enough to utilize as an outcome indicator.
The ratio of early to late neonatal deaths is consistent with estimates for Indonesia. About 67%
of all neonatal deaths in Kepri occurred in the first 7 days of life suggesting the importance of im-

% of Hospital
% Coverage
Cases
(reported pregnancies) 1

OB/GYN cases treated at hospital (includes normal deliveries)

5370

--

4.3% of all pregnancies

Complicated OB/GYN cases treated at


hospital 2

2358

47.3

--

0.27

4.1% of reported maternal


deaths (169 in 2004) occurred in hospital

Hospital admissions due to abortion

959

17.9

--

Caesarean sections

1137

21.2

1.0% of all deliveries

Case fatality rate 3

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)

86

Number *

* Hospital data from 2004 does not report Kepri separately from Riau. Therefore, these data include districts now in Kepri.
Data not reported at district level, so Kepri districts could not be extracted for this table.
1
Denominators from 2004 (Riau) data were pregnancies: 124,875; deliveries: 117,937.
2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.

Kepri hospital data was not reported separately from Riau in the most recently available database
from 2004. Reported data from hospitals in Riau indicate that about 4% of all deliveries occur in
hospital. Nearly half (47%) of these deliveries are classified as complicated.
The case fatality rate for complications is low
at 0.3% (WHO>1%), but only 4% of reported
maternal deaths occurred in hospital.
Nearly 18% of all hospital admissions are due
to abortion, suggesting a high rate of unsafe
abortion practices in Riau/Kepri. 21% of all
deliveries in hospital are by caesarean section, the high rate of complications among
hospital deliveries and low rate of hospital deliveries overal may be would make us to expect higher c/s rate. The c-section rate over all deliveries in the province is low at about 1% and
suggests that there are some women delivering outside of hospitals who would have had better
outcomes if delivered by c-section. Internationally, from 5-15% of women are expected to require
delivery by c-section for optimal maternal/neonatal outcome.

Provincial Reproductive Health & MPS Profile of Indonesia

KEPRI ISLANDS
BEONC UNMET NEED ACCORDING TO STANDARDS

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and LSS training. Ensure that
every puskesmas has at least one trained ANC midwife. With relatively high rates of SBA
coverage, the most important agenda for Kepri should be to aggressively upgrade the technical skills of those attendants and ensure adequate access to well-prepared facilities.
4. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they
drop out?
5. Community awareness of pregnancy risk, and active commitment to ensuring good referral
systems could contribute significantly toward even safer deliveries.
6. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.

WHO rec#
Total Unmet
Unmet
Total popPop. / ommended
District
BEONC Need (MOH:
need
ulation
BEONC coverage
in 2005 4 / district)
(WHO)
(1 / 125,000)
7
1 Kepri
1,235,054 *
3
1 411,685
10
5
2 Batam
591,253
0
4
-5
0
3 Karimun
204,251
5
0
40,850
2
1
4 Natuna
88,022
0
4
-1
1
5 Tanjung Pinang
157,923
0
4
-1
1
6 Lingga
77,930
0
4
-1
TOTAL
2,354,433
8
17 294,304
20
15

* This estimate of population size not consistent with reported population in this district in earlier years, and the BPS estimate of
319,482 in 2000. It is likely an error.

COVERAGE OF MIDWIFE PERSONNEL


Total reported deDistrict
liveries

Total APN midwives

Total LSS midwives

1 Kepri

5,198

2 Batam

16,880

3 Karimun

5,082

4 Natuna

2,365

5 Tanjung Pinang

4,199

6 Lingga

2,207

35,931

TOTAL

7. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


8. Review systems for documenting and counting population, total deliveries, and live births
to ensure these important denominators are reported accurately.
9. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
10. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
11. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Provincial Reproductive Health & MPS Profile of Indonesia

87

KEPRI ISLANDS
KEY INDICATORS AND NATIONAL TARGETS

Kepri

National Target

2001

2005 *

2007

2010

ANC1 (K1)

84

98

ANC4 (K4)

71

83

84

95

SBA deliveries

67

81

82

90

Postpartum / Neonatal visit (KN1)

51

86

83

90

Risk detection of pregnant women by community

1.0

21.2

Obstetric complications managed

Not reported

26.6

60

80

Neonatal complications managed

Not reported

10.9

60

80

Caesarian section rate (% of hospital deliveries)

30

21 *

Caesarian section rate (% of reported deliveries)

1.3 1

4.3 *

Hospital OB/GYN cases as % of all pregnancies

4.2 1

1.0 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

32 2

255

Data from 2001 Riau hospital database, including districts now in Kepri.
Data was calculated for districts in Kepri (Kep Riau, Batam, Karimun, Natuna) from Riau data report of 2001.
* c-sections and hospital data from 2004 Riau report, including districts now in Kepri.
1
2

88

Provincial Reproductive Health & MPS Profile of Indonesia

dki-JAKARTA

he capital city of Indonesia is now one of


the largest cities in Asia and the 9th most
densely populated city in the world. The
total population of Dearah Khusus Ibukota
(DKI Jakarta) is nearly 8 million, accounting for almost 4% of the total population in Indonesia, and
6% of the population in Java. DKI Jakarta is divided
into 6 districts (1 kabupaten + 5 kota [cities]) with a
total of 267 villages, though DKI Jakarta is classified as 100% urban.

GEOGRAPHY
Total land area (km2)

740

Number of districts

Kabupaten (regencies)

Kota (municipalities)

Kecamatan (sub-districts)

44

Kelurahan/Desa (villages)

267

Source: Beberapa Indikator Penting Sosial-Ekonomi


Indonesia, Edisi Juli 2006, BPS.

DKI Jakarta is led by a governor who reports to the


President of the Republic of Indonesia through the Minister of Home Affairs. The Local DeSOCIAL DEMOGRAPHY

DKI Jakarta

National

7,971,837

220,659,431

Percent urban population (2005) 2

100

48

Percent poor population (2004) 2

3.2

17

98

87

13.102

116

Life expectancy at birth (2002) 2

Male: 70
Female: 74

Male: 64
Female: 68

Annual growth rate (2000-2005) 2

0.80

1.34

Total population (2005)

Adult female literacy rate (2004)

Population density (km sq.; 2005)

Women of reproductive age

1,868,600

51,732,453 4

Total fertility rate / 1000 women 6

2.2

2.6

Crude birth rate / 1000 pop. (2000) 5

21.6

22.0

Percentage of women 15-19 who have begun childbearing 6

5.3

10.4

Modern contraceptive prevalence (%)

57.4

56.7

6.9

8.6

Unmet need for contraception (%)

From provincial health data reports.


2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

velopment Planning Board (BAPPEDA) sets the


guidelines for the local administration and helps
the governor to determine the strategic policies,
development and finance to the five municipalities in Jakarta and one administrative regency
(Kepulauan Seribu). The municipalities (hereafter referred to as districts) are Central, East,
West, North, and South Jakarta. Each of the five
districts in Jakarta has a mayor, while the Seribu
Islands are under a regent. In addition, there are also defined neighborhood units called Rukun
Tetangga (RT) and Rukun Warga (RW), which are under the jurisdiction of a sub-district.
DKI Jakarta has a much lower estimated proportion of people who are poor (3%) compared to the
national average. Adult female literacy is higher than the national rate at 98%.
The total fertility rate (2.2) and crude birth rate (21.6) are similar to the national average. The
modern contraceptive prevalence rate is higher (57%) is also similar to the national average, but
the percentage of young women who have begun childbearing is about half the national average (5.3%). Among all contraceptive users, predominant methods include injection (43%), oral
contraceptives (20%), IUD (16%), or traditional methods (9%). Condom use for contraception is
higher (5%) than in other provinces, but remains low as dual protection against sexually transmitted diseases, including HIV.

Health Facilities
DKI Jakarta reports 80 hospitals, almost three-quarters (58) of them private. There is excellent
coverage of specialists in both public and private hospitals. Not all districts reported these indicators so coverage is likely under-estimated.
Only 4 hospitals in two districts (Jakarta Selatan and Jakarta Utara) are reported to be certified as
providers of Comprehensive Emergency Obstetric and Neonatal Care (CEONC). The remaining
districts did not report this indicator.
DKI Jakarta has 333 puskesmas (primary health centers); puskesmas-based general practitioners
were not reported. Only 16% of all puskesmas have beds for in-patient care. The population covered

Provincial Reproductive Health & MPS Profile of Indonesia

89

DKI JAKARTA
by each puskesmas, on average, meets the recommended standard.

Health Personnel

Access to Basic Emergency Obstetric Care (BEONC or PONED)

On average, there is about one Ob/Gyn and one pediatric specialist for less than 30,000 population in DKI Jakarta. This is the best coverage of specialists in the country. Coverage of GPs was
not reported.

Fewer than 10% (33) of all puskesmas report having received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC). The current World Health Organization
(WHO) recommended standard for BEONC facilities is 1 for every 125,000 people. Indonesia has
adopted this indicator, but translated it to mean at least four BEONC facilities for each district.
There is a range of 0-12 BEONC facilities per district and nearly twice the population than recommended supported by each BEONC. In a heavily urban area where private delivery providers and
facilities are widely accessible, the role of BEONC puskesmas may be different than in more rural
areas. Still, in Kep. Seribu which is not only rural, but travel between islands and Jakarta may be
difficult in an emergency, there are no BEONC facilities reported.
Given the population size and density of Jakarta city, the standard of 4 BEONC per district would
likely not be adequate. The minimum recommended number of BEONC facilities based on total
population is 34, or 33 more than currently reported. The cost per puskesmas team (3 persons)
to be trained in BEONC is IDR 9.3 million (3.1 per person).
2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)


Hospitals with CEONC

22

58 2

Not reported

--

--

1 CEONC hospital / district

Not calculated due to


(WHO minimum standard: under-reporting
one / 500,000 pop.)

In-hospital OBGYN

31 4

272 4

--

1 / 752 pregnant
women

In-hospital pediatricians

45 3

210 3

--

1 / 785 newborn

One PHC / 30,000 pop.

1 / 23,939 pop.

Puskesmas
(primary health centers)

333

General practitioner in
Puskesmas

Not reported 5

--

--

52

--

16% of all puskesmas

Puskesmas with bed

4 / district
Puskesmas BEONC

33

(WHO minimum standard:


One / 125,000 pop.)

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.


2
Jakarta Timur did not report this indicator.
3
Jakarta Pusat, Jakarta Barat, Jakarta Timur and Kep. Seribu did not report this indicator.
4
Jakarta Pusat did not report this indicator.
5
Jakarta Pusat, Jakarta Utara, Jakarta Barat and Jakarta Timur did not report this indicator.
1

90

10% of all puskesmas


Average 5-6 / district;
Seribu reports none
1 / 241,571 pop.

Population coverage of midwives is below standard, despite an increase in midwives since 2001.
An additional 1157 midwives would be required to meet the standard of 1/3000 population. The
village midwife indicator was not calculated not being applicable. Only 3% of all midwives have
received APN training, and none are reported to have received LSS training.
All data on health facilities and personnel are under-reported by many districts from 2001-2005.
DKI Jakarta submitted largely blank HIS reports describing health facilities and personnel for
the years 2002, 2003 and 2004, so omissions in 2005 cannot be estimated from earlier years
reports.
HEALTH PERSONNEL
2001
2005
% Change
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
405 1
345 2
Pediatricians
358 1
293 2
Primary health center general prac386
Not reported 3
titioners (One GP / 30,000 pop.)
Nurses trained in ANC
350
Not reported
Total midwives
668
1500
(One / 3000 pop.)
Midwives with a kit
276 6
0
Midwives trained in APN
Not reported
45 5
Midwives trained in LSS
Total TBA
Trained TBA
TBA with kit

15%
17%
---

125%
---

Not reported

--

454
419
367

157
Not reported
Not reported

----

Jakarta Barat did not report this indicator.


Jakarta Pusat and Jakarta Timur did not report this indicator.
3
Only Jakarta Selatan reported this indicator.
4
Only Jakarta Utara reported this indicator.
5
Only Jakarta Selatan and Seribu reported this indicator.
6
Jakarta Barat and Jakarta Selatan did not report this indicator.

-1 / 5315 population
-3% midwives
1 / 2.7 million
population
---

1
2

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.
Assuming a crude birth rate in DKI Jakarta of 21.6 (BPS, 2000), the reported pregnancies are
19% higher that estimated pregnancies and reported deliveries are 17% higher than estimated
deliveries. The proportion of deliveries to pregnancies is also a bit lower than expected. The
discrepancy between reported events and estimated events is likely explained by the following

Provincial Reproductive Health & MPS Profile of Indonesia

DKI JAKARTA
DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported /
estimated 1

Reported pregnancies

227,877

2.86% of total population

119.2

Reported deliveries

210,881

92.5% of reported pregnancies

116.6

Reported newborn

200,112

94.9% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

factors: (a) the crude birth rate of 2005 may be higher than estimated and/or (b) the total population of Jakarta is higher than reported and/or (c) many women from outside Jakarta receive care
in Jakarta and are counted in Jakartas HIS data. For indicator calculation in this profile, reported
pregnancies, deliveries and newborn were used.

Antenatal Care Coverage


Among reported pregnancies, 91% of the women attended at least one antenatal visit (ANC1).
This drops to 75% coverage of 4 total antenatal
visits (ANC4), which is below the 2007 target of
84%. Although ANC1 coverage is relatively good,
the difference between ANC4 and ANC1 means
that over 35,000 women who have accessed
antenatal care once do not obtain the minimum
standard of 4 antenatal visits. These women are
either not adhering to the recommended antenatal
schedule or are accessing ANC too late to reach
4 visits. Quality of care, community awareness,
and logistical accessibility factors likely account for these missed opportunities. Over 20,000
pregnant women never accessed any antenatal care.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in DKI Jakarta. Nearly all (98%+) women report having an abdominal
examination, and weight and blood pressure measured, 91% received iron tablets. However,
only 35% report being informed of signs of pregnancy complications and only 71% report giving
a blood sample. Although DKI Jakarta has some of the best quality indicators for antenatal care
compared to the country overall, these last two indicators represent critical components of antenatal care and should be improved upon further.
There is minimal variation in reported antenatal coverage across districts in the city districts of
Jakarta. Kep Seribu reports lower ANC1 (47%) than the provincial average, and ANC4 coverage
that is higher than ANC1 (69%).

Skilled Birth Attendance


SBA data are not entirely consistent with
IDHS reports on place and attendance
at delivery. According to HIS reports, not
even three-quarters (70%) of all reported
deliveries are attended by a skilled health
professional (SBA=skilled birth attendant)
in DKI Jakarta. This indicator is below the
national target for 2007. And if these data
are valid, there are more than 62,500 deliveries unattended by a skilled birth attendant in the countrys capital city.
According to the IDHS, however, 89% of
women in DKI Jakarta deliver in a health
facility (mostly private) and 10% deliver at
home. More than twice the proportion of
women deliver with a doctor (26%) compared to only 11% in the country overall.
Attendance with a nurse/midwife (69%)
is also higher than the national average.
Fewer than 6% deliver with a TBA in DKI
Jakarta. If these estimates remain true in
2005, then more than 90% of women are
likely delivering with a skilled attendant in
DKI Jakarta.
It is difficult to comment on differences in
SBA coverage between city districts, but
Kep Seribu reports low SBA coverage at
only 45%. Variation in coverage of antenatal care and skilled birth attendance do
not show a consistent increasing trend toward higher coverage between 2001 and
2005. There is an inconsistent increasing
trend in ANC4 coverage which should be
interpreted with caution given the likely
errors and obvious omissions in the HIS
data from DKI Jakarta.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that over 88% of all births are officially registered in DKI Jakarta, among the highest rates in Indonesia (2nd only to Yogyakarta).

Provincial Reproductive Health & MPS Profile of Indonesia

91

DKI JAKARTA
Over 80% of all reported newborn attend the first and second neonatal visits (KN1, KN2), and 2%
attend KN1 only. The IDHS found lower rates of early postpartum/neonatal care attendance, and
slightly lower rates of missing care altogether (15%).

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate
of pregnant women detected as at risk by the community, including cadres, TBAs or other lay
persons (i.e. non-health professionals). Indonesia adopted that 20% of
all pregnant women will need medical
attention during pregnancy or delivery, or over 45,500 pregnant women
in DKI Jakarta annually (20% of all
pregnant women reported).
Overall, only 8% of this total number
of women was detected as being at
risk by community members, though
38% were detected by a health provider.

The predominant cause of maternal death in DKI


Jakarta is bleeding, though eclampsia plays a significant role. Key interventions to reduce risk of
hemorrhage should be emphasized (iron deficiency anemia control, trained midwives, appropriate
use of oxytocics in active management of
3rd stage as per national policy, access to
safe blood transfusion/fluid replacement).
Women with signs or symptoms of hypertensive disorders of pregnancy should be
70
treated properly and actively referred to
60
50
specialist care at a hospital, since early
40
delivery by c-section is the most effective
30
measure to prevent progression to ec20
10
lampsia and death.

Causes of Maternal Deaths, 2005


infection
10%

eclampsia
23%

other /
unknown
17%

bleeding
50%

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)
60
39

37

33

22

2001

2002

2003

2004

2005

It should be noted that 17% of all maternal


deaths are not attributed to any immediate cause of death. More importance should be attached to correctly diagnosing and recording
causes of maternal deaths in order to more closely track progress toward effective management
of obstetric complication and identify potential interventions to reduce maternal mortality. This
especially in a city with many specialists.
The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Due
to under-reporting and lack of reporting in 3 districts, neonatal mortality was not calculated (only
311 deaths reported total). The national estimate is 18 neonatal deaths per 1000 births (WHO,
2006). According to IDHS 2002/2003 data, the neonatal mortality rate is 18/1000 births, it is equal
to national estimate.

Management of maternal or neonatal complications was not reported. The national target for
obstetric and neonatal complications management is 60% by 2007 and 80% by 2010.

The ratio of early to late neonatal deaths was also not calculated because only 23 deaths were
reported by age. About three-quarters of all neonatal deaths in Indonesia occur in the first 7 days
of life suggesting the importance of improving quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g. resuscitation, infection prevention, early detection and
treatment of sepsis, and management of low birth weight newborn).

Maternal and Neonatal Deaths

The reported stillbirth rate is 7.2 / 1000 estimated deliveries in DKI Jakarta compared to the national estimate of 17.

There were 70 maternal deaths reported in DKI Jakarta in 2005 through the HIS, less than 2% of
all reported maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 33 /
100,000 live births. This is far smaller than national estimates (MMR=230, range 58 to 440, WHO
/ UNICEF / UNFPA, 2000 or MMR=307, IDHS, 2002/3) and suggests under-reporting, though the
MMR in DKI Jakarta may indeed be lower than the national average.
The hospital data report from 2004 reported 227 deaths, while the HIS in 2004 counted only 41.
The HIS clearly under-counts maternal deaths.

92

Hospital Management of Maternal and Neonatal Complications


Reported data from hospitals in DKI Jakarta indicate that over 13% of all deliveries occur in hospital. One-third (36%) of these deliveries are classified as complicated.
The case fatality rate for complications among hospital deliveries is high at 2.3% (WHO > 1%).
Due to serious under-counting of maternal deaths in the routine HIS, over 500% of officially re-

Provincial Reproductive Health & MPS Profile of Indonesia

DKI JAKARTA
ported maternal deaths occur in hospital.
Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
Number

% of Hospital
Cases

% Coverage
(reported pregnancies) 1

OB/GYN cases treated at hospital (includes normal deliveries)

28,034

--

13.3% of all pregnancies

Complicated OB/GYN cases treated at


hospital 2

10,110

36.1

--

Case fatality rate 3

227

2.25

>500% it is reported maternal


deaths (41 in 2004) occurred
in hospital

Hospital admissions due to abortion

3689

13.2

--

14,512

51.8

7.2% of all deliveries

HOSPITAL CASES

Caesarean sections

Denominators from 2004 data were pregnancies: 210,200; deliveries: 200,645.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.

2. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one midwife trained in ANC.
3. Improve management of obstetric and neonatal complications.
4. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
5. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


6. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
7. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Over 13% of all hospital admissions are due to


abortion, suggesting a high rate of unsafe abortion practices in DKI Jakarta. About 52% of all
deliveries in hospital are by caesarean section.
The c-section rate among all deliveries in the
province is 7.2%, the highest in the country. This
relatively high rate is consistent with international
expectations about the proportion of women who
are expected to require delivery by c-section for
optimal maternal/neonatal outcome. However,
whether the women delivered by c-section are all truly medically necessary cannot be evaluated.
It is likely that many women are having unnecessary c-sections, and many others who require
surgical delivery are not accessing the care they need.

Recommendations
Coverage of health personnel and service inputs
1. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.

8. Given the predominance of private hospitals in DKI Jakarta, investigate data quality and
completeness at private versus public hospitals to identify gaps or weaknesses (i.e. no private hospital reported CEONC certification, what proportion of obstetric cases are handled
in private vs. public ).
9. Review systems for documenting and counting total pregnancies, deliveries, and live births
to ensure these important denominators are as accurate and consistent as possible. Investigate how data of vital events and health service visits are recorded and reported for
women who receive medical care in districts where they do not reside.

District

BEONC UNMET NEED ACCORDING TO STANDARDS


WHO recTotal Unmet
Unmet
Total pop- # BEONC
Pop. / ommended
Need (MOH:
need
ulation
in 2005
BEONC coverage
4 / district)
(WHO)
(1 / 125,000)

1 Jakarta Pusat

910,168

113,771

2 Jakarta Utara

1,435,207

478,402

11

3 Jakarta Barat

1,937,156

322,859

16

10

4 Jakarta Selatan

1,707,931

426,983

14

10

5 Jakarta Timur

1,965,175

12

163,765

16

16,200

--

7,971,837

33

241,571

34

33

6 Kep. Seribu
TOTAL

Provincial Reproductive Health & MPS Profile of Indonesia

93

DKI JAKARTA
COVERAGE OF MIDWIFE PERSONNEL
District

Total reported deliveries

Total LSS
midwives

Total APN midwives

1 Jakarta Pusat

23,675

2 Jakarta Utara

37,859

3 Jakarta Barat

45,538

4 Jakarta Selatan

46,732

44

5 Jakarta Timur

56,541

536

210,881

45
(coverage not calculated
due to under-reporting)

6 Kep. Seribu
TOTAL

KEY INDICATORS AND NATIONAL TARGETS

DKI Jakarta
2001

National Target
2005 *

2007

2010

ANC1 (K1)

92

91

ANC4 (K4)

66

76

84

95

SBA deliveries

72

70

82

90

Not reported

82

83

90

7.2

7.5

Obstetric complications managed

Not reported

Not reported

60

80

Neonatal complications managed

Not reported

Not reported

60

80

Caesarian section rate (% of hospital deliveries)

37

52 *

Caesarian section rate (% of reported deliveries)

9.7

7.2 *

Hospital OB/GYN cases as % of all pregnancies

25.9

13.3 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

37

33

Postpartum / Neonatal visit (KN1)


Risk detection of pregnant women by community

* c-sections and hospital cases from 2004 data.

94

Provincial Reproductive Health & MPS Profile of Indonesia

WEST
JAVa

he total population of West Java is 39 million,


accounting for nearly 18% of the total population in Indonesia, and 30% of the population in
Java. West Java is divided into 25 districts (16
kabupaten + 9 kota [cities]) with a total of 5808 villages.
The capital city is Bandung.

GEOGRAPHY

Total land area (km2)


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

36,925
25
16
9
592
5808

Source: Beberapa Indikator Penting Sosial-

West Java has a much higher urban population (59%)


Ekonomi Indonesia, Edisi Juli 2006, BPS.
and lower poor population (12%), compared to the national average. Adult female literacy is slightly higher than the national rate at 91%.

The total fertility rate (2.8), crude birth rate (22.6) and modern contraceptive prevalence rate
(57%) are similar to the national average, but nearly 15% of young women ages 15-19 have
begun childbearing, compared to 10% in Indonesia overall. Among all contraceptive users, most
women choose injection (55%) or oral contraceptives (27%).
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005)
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6
2

West Java
38,949,678
59
12
91
1129
Male: 63
Female: 66
1.81
9,129,810 3
2.8
22.6
14.7
57.5
9.9

National
220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population,
using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

Health Facilities
West Java reports 123 hospitals; almost two-thirds
of them are private. Fewer than 60% of public
hospitals report having specialists in Ob/Gyn or
pediatrics. The presence of specialists in private
hospitals was not reported.
Over half of all public hospitals (26) are certified
as providers of Comprehensive Emergency ObHEALTH FACILITIES

2005
Public

Private

Indonesia minimum standard

Coverage

Rows bordered in red are below minimum standard


Total hospitals (general)

44

79

-1 CEONC hospital
/ district

1 / district
<1 / 500,000 pop.

Hospitals with CEONC 1

26

Not reported

In-hospital OBGYN

27

Not reported

--

1 / 36,408 pregnant women

In-hospital pediatricians

26

Not reported

--

1 / 35,080 newborn

(WHO minimum
standard:
one / 500,000 pop.)

Puskesmas
(primary health centers)

989

One PHC / 30,000


pop.

1 / 39,383 pop.

General practitioner in
Puskesmas

648 2

--

1 / 60,108 pop.

Puskesmas with bed

146

--

15% of all puskesmas

4 / district

8% of all puskesmas

(WHO minimum
standard:
One / 125,000
pop.)

Average 3/district; 5/25


districts have none

Puskesmas BEONC

1
2

80

1 / 48,687 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.


Seven districts (Karawang, Bogor, Majalengka, Kota Bekasi, Kota Tasikmalaya, Kota Cirebon, Kota Depok) did not
report this indicator.

Provincial Reproductive Health & MPS Profile of Indonesia

95

WEST JAVA
stetric and Neonatal Care (CEONC). The distribution of CEONC centers, however, does not
cover all districts; four districts report not having a CEONC hospital (Kab Sukabumi, Kab Indramayu, Kota Bekasi, Kota Cirebon). Some private hospitals may provide CEONC service, but
there are no data reported from private hospitals on this indicator.
West Java has 989 puskesmas (primary health centers). Provincial coverage of general practitioners working in puskesmas could not be evaluated because seven districts did not report.
However, adjusted coverage for reporting districts was one puskesmas for more than 43,000
people, which does not meet the recommended standard of 1 / 30,000. Only 15% of puskesmas
have beds for in-patient care.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 80 of all puskesmas (8%) report having received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO) recommended standard for BEONC facilities is 1 per every 125,000 people. Indonesia has adopted this
indicator, but translated it to mean at least four BEONC facilities for each district.
If the 2005 HIS report is accurate, only 80 BEONC facilities is extremely inadequate coverage for
West Java. If every district had 4 BEONC, an additional 32 would be required. However, since
West Java is so heavily populated, the recommended number of BEONC facilities according to
population size is 312, or 233 more than currently reported.
One immediate step would be to upgrade the staff and facilities of each puskesmas with BEONC
skills, focusing first on districts currently under-served by BEONC and CEONC facilities (Kab
Sukabumi, Kab Indramayu, Kota Cirebon). Later efforts could be continued to reach the WHO
recommended number of BEONC facilities in each district. The cost per puskesmas team (3
persons) to be trained in BEONC is 9.3 million (3.1 per person).

Health Personnel
On average, there is one Ob/Gyn specialist for every 530,000 population, and one pediatrician
for every 640,000 population. The total number of general practitioners meets the recommended
standard. But population coverage of midwives is below standard. An additional 6550 midwives
would be required to meet the standard of 1/3000 population. Just more than half (54%) of all
villages are reported to have a midwife living in the village. Less than 1 in 5 (19%) of all midwives
has received APN training, and even fewer have received LSS training.
The data on reported health personnel is blank for all indicators in 2001 and many districts in
2002, making it difficult to identify improving or deteriorating trends in coverage over time. For this
reason we are taking in consideration only year 2005.

96

HEALTH PERSONNEL
2005
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs

73 1

Pediatricians

61 1

Primary health center general practitioners


(One GP / 30,000 pop.)

1434

Nurses trained in ANC

1 / 27,162 population

Not reported 2

Total midwives
(One / 3000 pop.)

6432

1 / 6056 population

Midwives living in the village


(One / village)

3118

54% of villages have village midwife

Midwives with a kit

412

1 / 94,538 population

Midwives trained in APN

1202

19% of midwives

Midwives trained in LSS

1004

1 / 38,795 population

Total traditional birth attendants (TBA)

12,786 3

Trained TBA

995 4

Not calculated due to under-reporting

TBA with kit

1903

Not calculated due to under-reporting

Four districts (Sukabumi, Indramayu, Kota Bekasi, Kota Cirebon) did not report this indicator.
Only 2 districts reported this indicator.
3
Six districts (Bekasi, Karawang, Bogor, Sukabumi, Majalengka, Kota Tasikmalaya) did not report this indicator.
4
Eleven of 25 districts did not report this indicator.
1
2

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in West Java of 22.6 (BPS, 2000), the reported pregnancies are less
than 1% higher than the estimated pregnancies, and reported deliveries are 2% higher than estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries is valid
and consistent with the country overall. These consistencies suggests that the crude birth rate
DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported
/ estimated 1

Reported pregnancies

983,009

2.52% of total population

100.6

Reported deliveries

944,435

96.1% of reported pregnancies

102.2

Reported newborn

912,072

96.6% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.

A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.

Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.

Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Provincial Reproductive Health & MPS Profile of Indonesia

WEST JAVA
for West Java has probably not changed much since 2005, and that registration and reporting of
pregnancies, deliveries and newborn born is quite accurate.

Antenatal Care Coverage


Among reported pregnancies, 86% of the women attended at least one antenatal visit (ANC1).
This drops to 77% coverage of 4 total antenatal
visits (ANC4), which is below the 2007 target of
84%. The difference between ANC4 and ANC1
shows that nearly 93,000 women who have accessed antenatal care once do not obtain the
minimum standard of 4 antenatal visits. These
women are either not adhering to the recommended antenatal schedule or are accessing
ANC too late to reach 4 visits. Quality of care, community awareness, and logistical accessibility
factors likely account for these missed opportunities. Over 138,000 pregnant women never accessed any antenatal care.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in West Java. More than 90% of women report having an abdominal examination, their weight and their blood pressure measured, and 76% received iron tablets. However,
only 16% report being informed of signs of pregnancy complications and only 25% gave a blood
sample.
There is minimal variation in reported antenatal coverage by most districts, however, two districts, Kab
Tasikmalaya and Kota Sukabumi, report low rates of ANC1 (64% and 71% respectively) and Kab
Tasikmalaya and Kota Cirebon report low rates of ANC4 (57% and 64% respectively) compared to
the provincial average.

Skilled Birth Attendance


Two out of three (67%) of all reported deliveries are attended by a skilled health professional
(SBA=skilled birth attendant). This leaves nearly 313,000 women delivering without any skilled birth
attendant. The national target for skilled birth attendance is 82% by 2007 and 90% by 2010.

pared to the national estimates (55%),


and a higher proportion by TBAs (50%
vs. 32% nationally) or by a doctor (7% vs.
11% nationally).

The majority of women deliver at health


facilities. Over 71% of women delivered
at a private health facility, more than
twice the national estimate of 30%, and
nearly 18% delivered at a public health
facility, also twice the national estimate.
These estimates do not provide a breakdown between hospital and non-hospital deliveries. Only 11% delivered at
home.
Two districts, Kab Tasikmalaya (48%)
and Kab Cianjur (50%), report lower
skilled birth attendant coverage rates
compared to the provincial average.
Trends in coverage of antenatal care and skilled birth attendance from 2001-05 do not show any
significant change in coverage of either indicator.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that fewer than 42% of all births are officially registered in West Java which
is lower than the national estimated level (54%). Over 80% of all reported newborn attend the
first neonatal visit (KN1), and nearly all of those women also attend the second (KN2, 79%).
The IDHS found lower rates of early postpartum/neonatal care, but similar rates of missing care
altogether (19%).
The data on postpartum/neonatal coverage are not entirely consistent when examined by district.
Two districts report very low KN1 rates (Kab Sukabumi: 58% and Kab Sumedang: 51%), but those
two districts (plus 4 more: Kab Bandung, Kota Bekasi, Kota Sukabumi, Kota Cimahi) report higher
rates of KN2 than KN1, suggesting errors in reported KN1 and/or KN2 coverage.

A lower proportion of women delivering in West Java are attended by a nurse/midwife (42%) com-

Provincial Reproductive Health & MPS Profile of Indonesia

97

WEST JAVA
Risk Detection and Management of Complications
In Indonesia one of the indicator measuring
progress toward making pregnancy safer
is the rate of pregnant women detected as
at risk by the community, including cadres, TBAs or other lay persons (i.e. nonhealth professionals). Indonesia adopted
that 20% of all pregnant women will need
medical attention during pregnancy or delivery, or nearly 200,000 pregnant women
in West Java annually (20% of all pregnant
women reported).
There was significant lack of reporting on these indicators. Only 6 districts reported community
risk detection, and 8 districts reported health provider risk detection. Overall, only 38% of this
total number of women expected to be at risk (20% pregnancies) were detected as being at risk
by community members and 57% were detected by a health provider (denominator adjusted, applicable to reporting districts only).
Less than 19% of all expected maternal complications (20% of pregnancies) were managed by
the health care system at primary or tertiary levels of care. The national target for obstetric
complications management is 60% by 2007 and 80% by 2010. West Java is far below national
expectations on this indicator. Six districts reported zero, which probably means they did not
tally and report management of obstetric complications in those districts.
Management of neonatal complications (estimated to be 25% of newborn) appears to be even
lower. While the national target for 2007 is 60%, increasing to 80% in 2010, West Java reports
managing less than 4% of all expected neonatal complications. Twelve districts reported zero,
which probably means they did not tally and report management of neonatal complications in
those districts.

Causes of Maternal Deaths, 2005


bleeding
39%

eclampsia
18%

other /
unknown

infection
7%

36%

Maternal Mortality Ratio, 2001-05


(deaths / 100,000 reported newborn)

The number of reported stillbirths and neona160


138
tal deaths indicates serious under-reporting.
140
120
103
Based on reported data, West Java has a
100
neonatal mortality rate of only 3.7 compared
80
60
to a national estimate of 18 neonatal deaths
40
20
per 1000 births (WHO, 2006). The IDHS
0
2002/2003 is also present a higher neonatal
2001
2002
mortality rate (25/1000 births).Therefore, it is
unlikely that the West Java data on neonatal
mortality are accurate enough to utilize as an outcome indicator.

94

2003

74

68

2004

2005

The ratio of early to late neonatal deaths is consistent with international estimates, and it should
be emphasized that over 77% of neonatal deaths occurred in the first 7 days of life suggesting
the importance of improving quality and access to pregnancy care, safer delivery and emergency
neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis,
and management of low birth weight newborn).
The reported stillbirth rate is 3.2 / 1000 estimated deliveries in West Java compared to the national estimate of 17.

Hospital Management of Maternal and Neonatal Complications

Maternal and Neonatal Deaths


There were 624 maternal deaths reported in West Java in 2005, nearly 15% of all reported maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 68 / 100,000 live births.
This is smaller than national estimates (MMR=230, range 58 to 440, WHO/UNICEF/UNFPA, 2000
or MMR=307, IDHS, 2002/3) and suggests serious under-reporting, though the MMR in West
Java may indeed be lower than the national average.
The predominant cause of maternal death in West Java is bleeding, though eclampsia plays
a significant role. Key interventions to reduce risk of hemorrhage should be emphasized (iron
deficiency anemia control, trained midwives, appropriate use of oxytocics in active management
of 3rd stage as per national policy, access to safe blood transfusion/fluid replacement). Women
with signs or symptoms of hypertensive disorders of pregnancy should be treated properly and
actively referred to specialist care at a hospital, since early delivery by c-section is the most effective measure to prevent progression to eclampsia and death.

98

It should be noted that more than one-third


(36%) of all maternal deaths are not attributed to any immediate cause of death. More
importance should be attached to correctly
diagnosing and recording causes of maternal deaths in order to more closely track
progress toward effective management of
obstetric complication and identify potential
interventions to reduce maternal mortality.

Reported data from hospitals in West Java indicate that fewer than 3% of all deliveries occur in
hospital. Over half (52%) of these deliveries are
classified as complicated.
The case fatality rate for complications among
hospital deliveries is low at 0.4% (WHO>1%) and
but 8% of all reported maternal deaths occurred
in the hospital. It is unlikely that fewer than 1 in
10 maternal deaths occur in a hospital for such
a densely populated and largely urban province where the majority of deliveries reportedly take
place in a health facility. These data suggest that maternal deaths are under-reported by the community and primary health workers, and may also be under-reported by hospitals.

Provincial Reproductive Health & MPS Profile of Indonesia

WEST JAVA
HOSPITAL CASES

% of Hospital
% Coverage
Number
Cases
(reported pregnancies) 1

OB/GYN cases treated at hospital (includes normal deliveries)

25,759

--

2.7% of all pregnancies

Complicated OB/GYN cases treated at


hospital 2

13,260

51.5

--

52

0.39

8.3% of reported maternal


deaths (626 in 2004) occurred in hospital

Hospital admissions due to abortion

3916

15.2

--

Caesarean sections

9693

37.6

1.1% of all deliveries

Case fatality rate 3

Denominators from 2004 data were pregnancies: 937,703; deliveries: 894,123.


Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1
2

Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
Over 15% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion
practices in West Java. The high rate of complicated cases handled in hospital, cause 38% of all
deliveries in hospital be by caesarean section. The c-section rate over all deliveries in the province is 1% and suggests that there are many women delivering outside of hospitals who would
have had better outcomes if delivered by c-section. Internationally, from 5-15% of women are
expected to require delivery by c-section for optimal maternal/neonatal outcome.

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need to investigate apparent deficiencies, reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.

4. Investigate the reason behind relatively low ANC1 coverage. Why do so many women never access antenatal care? Investigate the reasons behind the difference between ANC4
and ANC1 rates of attendance. Who are these women entering the system but not being
retained? Why do they drop out?
5. Increase the number of women who deliver with a skilled birth attendant, and the proportion
of newborn and postpartum mothers who receive postnatal care.
6. Improve management of obstetric and neonatal complications.
7. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
8. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


9. Investigate data reporting discrepancies between kota and kabupaten at primary health
care levels (BEONC, nurses, midwives).
10. Given the predominance of private hospitals in West Java, investigate data quality and
completeness at private versus public hospitals to identify gaps or weaknesses (i.e. no private hospital reported CEONC certification, what proportion of obstetric cases are handled
in private vs. public ).
11. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
12. Investigate reasons behind lack of data reporting in many years, and incomplete data in
other years. District level comparisons and trend analysis is difficult to conduct with 2001-5
reported data.
13. Investigate data quality of all health input data both facility and personnel. These data
are critical for evaluating distribution of resources, and where to invest in increasing health
infrastructure to ensure equal access within the province.
14. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

3. Increase the number of midwives who have received APN and BEONC training, particularly
in districts reporting none. Ensure that every puskesmas has at least one trained ANC
midwife.

Provincial Reproductive Health & MPS Profile of Indonesia

99

WEST JAVA
BEONC UNMET NEED ACCORDING TO STANDARDS
District
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Total
population

Kab. Bekasi
1,917,248
Kab. Karawang
1,939,674
Kab. Purwakarta
798,218
Kab. Subang
1,379,534
Kab. Bogor
3,945,411
Kab. Sukabumi
2,274,899
Kab. Cianjur
2,118,122
Kab. Bandung
4,134,504
Kab. Sumedang
996,592
Kab. Garut
2,275,951
Kab. Tasikmalaya 1,578,571
Kab. Ciamis
1,453,139
Kab. Cirebon
2,068,621
Kab. Kuningan
1,048,770
Kab. Majalengka
1,158,192
Kab. Indramayu
1,663,867
Kota Bekasi
831,571
Kota Bogor
278,418
Kota Sukabumi
2,269,874
Kota Bandung
286,294
Kota Tasikmalaya 1,931,976
Kota Cirebon
1,353,249
Kota Cimahi
576,087
Kota Depok
509,189
Kota Banjar
161,707
TOTAL 38,949,678

#
Total Unmet
Pop. /
BEONC Need (MOH:
BEONC
in 2005 4 / district)
3
3
3
3
4
4
5
4
4
5
4
4
4
4
9
3
9
1
0
2
0
2
0
0
0
80

1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
1
0
3
4
2
4
2
4
4
4
32

639,083
646,558
266,073
459,845
986,353
568,725
423,624
1,033,626
249,148
455,190
394,643
363,285
517,155
262,193
128,688
554,622
92,397
278,418
-143,147
-676,625
---486,871

WHO recUnmet
ommended
need
coverage
(WHO)
(1 / 125,000)
15
16
6
11
32
18
17
33
8
18
13
12
17
8
9
13
7
2
18
2
15
11
5
4
1
312

12
13
3
8
28
14
12
29
4
13
9
8
13
4
0
10
0
1
18
0
15
9
5
4
1
233

COVERAGE OF MIDWIFE PERSONNEL


Total reported
District
deliveries
Kab. Bekasi
1
49,043
Kab.
Karawang
2
57,175
Kab. Purwakarta
3
20,564
Kab. Subang
4
34,991
Kab. Bogor
5
107,989
Kab. Sukabumi
6
59,147
Kab.
Cianjur
7
56,130
Kab. Bandung
8
85,271
Kab. Sumedang
9
25,475
10 Kab. Garut
48,086
Kab.
Tasikmalaya
11
50,356
12 Kab. Ciamis
32,058
13 Kab. Cirebon
55,854
14 Kab. Kuningan
27,447
Kab.
Majalengka
15
22,592
16 Kab. Indramayu
31,710
17 Kota Bekasi
45,420
18 Kota Bogor
20,395
Kota
Sukabumi
19
7,841
20 Kota Bandung
44,637
21 Kota Tasikmalaya
14,978
22 Kota Cirebon
6,245
Kota
Cimahi
23
10,384
24 Kota Depok
26,118
25 Kota Banjar
4,529
TOTAL

944,435

KEY INDICATORS AND NATIONAL TARGETS

West Java
2001

2005 *

ANC1 (K1)

85

86

ANC4 (K4)

75

SBA deliveries
Postpartum / Neonatal visit (KN1)

Total LSS midwives


130
140
3
195
47
4
12
0
5
5
189
0
0
238
0
21
0
0
0
0
0
0
0
0
15
1004
1 / 941 deliveries)
National Target
2007

2010

77

84

95

68

67

82

90

84

80

83

90

Risk detection of pregnant women by community

Not reported

37.7

Obstetric complications managed

Not reported

18.8

60

80

Neonatal complications managed

Not reported

2.0

60

80

Caesarian section rate (% of hospital deliveries)

31

38 *

Caesarian section rate (% of reported deliveries)

1.4

1.1 *

Hospital OB/GYN cases as % of all pregnancies

6.2

2.7 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

138

68

* c-sections and hospital cases from 2004 data.

100

Total APN midwives


34
44
72
20
24
14
29
122
63
93
61
50
215
141
35
18
0
4
0
86
0
60
0
0
17
1202
(1 / 786 deliveries)

Provincial Reproductive Health & MPS Profile of Indonesia

CENTRAL
JAVa

he total population of Central Java is over 32 million, accounting for nearly 15% of the total population in Indonesia, and 25% of the population in
Java. Central Java is divided into 35 districts (29
kabupaten + 6 Kota [cities]) with a total of 8566 villages.
The capital is Semarang.

GEOGRAPHY

Total land area (km2)


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

32,800
35
29
6
565
8566

Source: Beberapa Indikator Penting Sosial-

Ekonomi Indonesia, Edisi Juli 2006, BPS.


Central Java has a similar urban population (49%) and
higher poor population (21%) compared to the national
average. Adult female literacy is lower than the national rate at 82%.

The total fertility rate (2.1) and crude birth rate (19.9) are lower than the national average. The
modern contraceptive prevalence rate is higher (62%) and the percentage of young women who
have begun childbearing is slightly lower than the national average (9.1%). Among all contraceptive users, most women choose injection (50%). Other methods include oral contraceptives
(14%), implants (11%), IUD (9%), tubal ligation/vasectomy (9%) or traditional methods (5%).
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

Central Java

National

32,386,587
49
21
82
980
Male: 67
Female: 71
0.42
7,591,420 3
2.1
19.9

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0

9.1

10.4

62.2
6.5

56.7
8.6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population,
using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1
2

Health Facilities
Central Java reports a total of 146 hospitals, over half
(59%) of them private. There is good coverage of specialists in hospitals with more than one specialist, on
average, in public hospitals. Not all private hospitals
have specialist staff, however.

Half of all hospitals (73) are certified as providers of


Comprehensive Emergency Obstetric and Neonatal
Care (CEONC) with at least one per district (except
for Kab Kendal which either did not report or has zero). Since there are more CEONC providers
than public hospitals, some of these CEONC providers must be private hospitals.
Central Java has 841 puskesmas (primary health centers) with as many puskesmas-based general
practitioners (845). One-quarter (25%) of puskesmas have beds for in-patient care.

2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

59

Hospitals with CEONC

73

In-hospital OBGYN
In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in
Puskesmas
Puskesmas with bed
Puskesmas BEONC
1

87
85

87

1 CEONC hospital / district


Not reported (WHO minimum standard:
one / 500,000 pop.)
64
-58
--

--

>2 / district
>1 / 500,000 pop.
1 / 4336 pregnant women
1 / 4175 newborn

841

One PHC / 30,000 pop.

1 / 38,510 pop.

845

--

--

208

--

138

4 / district
(WHO minimum standard:
One / 125,000 pop.)

25% of all puskesmas


16% of all puskesmas
Average 4/district; 7 of 35
districts have none
1 / 234,685 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.

Access to Basic Emergency Obstetric Care (BEONC or PONED)

Provincial Reproductive Health & MPS Profile of Indonesia

101

CENTRAL JAVA
Only 138 puskesmas (16%) report having received training and certification in Basic Emergency
Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO) recommended standard for BEONC facilities is 1 per every 125,000 people. Indonesia has adopted this
indicator, but translated it to mean at least four BEONC facilities for each district.
Most districts report at least one BEONC facility, ranging from 1-16 per district. However, seven
districts report zero (see BEONC unmet need table at end of this profile). On average, twice
the population is supported by each BEONC than recommended. For every district to have 4
BEONC, an additional 44 would be required. However, given the population size of Central
Java, the recommended number of BEONC facilities is 259. Taking into account variation in coverage by population density, an additional 132 BEONC facilities are recommended.
One immediate step would be to upgrade each puskesmas with a bed to BEONC level, focusing
first on districts currently under-served by BEONC and CEONC facilities (Kota Salatiga, Kota
Semarang, Pati, Blora, Kota Tegal, Kota Magelang, Kota Surakarta, Boyolali, Sragen, Krnganyar). Later efforts could be continued to reach the WHO recommended number of BEONC
facilities in each district. The cost per puskesmas team (3 persons) to be trained in BEONC is 9.3
million (3.1 per person).

Health Personnel
HEALTH PERSONNEL
2001
2005 % Change
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives (One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in LSS
Total TBA
Trained TBA
TBA with kit

91
91

159
141

75%
55%

1301

1374

6%

1073
7247

1076
7391

Same
2%

5184

5068

2%

5181
5368
Not reported
835
Not reported 1121
21,689
20,548
19,274
18,226
17,264
17,005

4%
-- 5%
5%
2%

1 / 23,571 population

1 / 4382 population
59% of villages have
village midwife
1 / 6033 population
11% midwives
1 / 28,891 population
89% of all TBA
83% of all TBA

The total number of specialists in Central Java has grown substantially since 2001. On average, there is one Ob/Gyn specialist for every 200,000 population, and one pediatrician for every
230,000 population. Coverage of GPs now exceeds the recommended standard. However, population coverage of midwives is below standard. An additional 3400 midwives would be required
to meet the standard of 1/3000 population. Less than 60% of all villages report having a midwife

102

living in the village, and this coverage has remained steady since 2001. Only 1 in 9 (11%) of all
midwives has received APN training, and 15% are reported to have received LSS training.

Primary Health Care Indicators


DENOMINATORS FOR KEY
INDICATORS

Number

Ratio of reported /
estimated 1

Reported pregnancies

654,664

2.02% of total population

91.5

Reported deliveries

623,999

95.3% of reported pregnancies

92.2

Reported newborn

597,000

95.7% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.
Assuming a crude birth rate in Central Java of 19.9 (BPS, 2000), the reported pregnancies are
lower (8.5%) than the estimated pregnancies, and reported deliveries are similarly lower (8%)
than estimated deliveries. However, the proportion of deliveries to pregnancies, and newborn
to deliveries is valid and consistent with the country overall, suggesting that the reported events
are reasonably accurate in relation to one-another, though they may all be under-counted. Other
likely explanations for this lower number of actual pregnancies, deliveries and newborn events
compared to expected number may be that the crude birth rate in Central Java is lower than estimated or the population is lower than reported.

Antenatal Care Coverage


Among reported pregnancies, 88% of the women attended at least one antenatal visit (ANC1).
This drops to 79% coverage of 4 total antenatal
visits (ANC4), which is below the 2007 target of
84%. The difference between ANC4 and ANC1
shows that nearly 59,000 women who have accessed antenatal care once do not obtain the
minimum standard of 4 antenatal visits. These
women are either not adhering to the recommended antenatal schedule or are accessing
ANC too late to reach 4 visits. Quality of care,
community awareness, and logistical accessibility
factors likely account for these missed opportunities. Over 78,000 pregnant women never accessed any antenatal care in Central Java.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of an-

Provincial Reproductive Health & MPS Profile of Indonesia

CENTRAL JAVA
tenatal care provided in Central Java. More than 94% of women report having an abdominal
examination, weight and blood pressure measured, and 89% received iron tablets. However,
only 37% report being informed of signs of pregnancy complications and only 35% gave a blood
sample. Although Central Java has one of the best quality indicators for antenatal care compared
to the country overall, these last two indicators represent critical components of antenatal care
and should be improved upon further.
There is minimal variation in reported antenatal coverage by most districts, however, two districts,
Tegal and Purworedjo, report low rates of ANC1 (25% and 42% respectively) and ANC4 (21%
and 38% respectively) compared to the provincial average. One district, Wanogiri, was excluded
from the ANC1 coverage calculations due to over-reporting (140%).

The IDHS estimates that nearly 74% of all births are officially registered in Central Java, higher
than the national average. About 77% of all reported newborn attend the first and second neonatal visits (KN1, KN2) and 8% attend KN1 only. The IDHS found higher rates of postpartum/neonatal care attendance, and slightly lower rates of missing care altogether (11%).
Four districts (Klaten, Banyumas, Brebes, Grobogan) did not report KN2 attendance, which was
denominator adjusted for those missing districts.

Risk Detection and Man-

Skilled Birth Attendance


More than 3 out of 4 (77%) of all reported deliveries are
attended by a skilled health professional (SBA=skilled
birth attendant). This leaves more than 151,000 women delivering without any skilled birth attendant. The
national target for skilled birth attendance is
82% by 20v07 and 90% by 2010.
Central Java closely mirrors the national
average of birth attendance and place of
delivery estimates from the IDHS: About
11% are attended by a doctor, 56% by
a midwife or nurse, and 32% by a TBA.
Over 40% deliver at a health facility (public or private), and 59% deliver at home.
Again, there is minimal variation in reported SBA coverage by most districts, however, the same two districts, Tegal and
Purworedjo, report very low rates of SBA
coverage (18% and 35% respectively).
Variation in antenatal care and SBA coverage shows a trend toward higher coverage between 2001 and 2005. Antenatal
care coverage (ANC4) increased about 4
percentage points, and SBA coverage increased about 10 percentage points.

Postpartum (Neonatal) Care


Coverage

agement of Complications
In Indonesia one of the indicator measuring
progress toward making pregnancy safer is
the rate of pregnant women detected as at
risk by the community, including cadres,
TBAs or other lay persons (i.e. non-health
professionals). Indonesia adopted that
20% of all pregnant women will need medical attention during pregnancy or delivery,
or nearly 131,000 pregnant women in Central Java annually (20% of all pregnant
women reported).
Overall, only 38% of this total number of
women was detected as being at risk by community members and 67% were detected by a
health provider (denominator adjusted, applicable to reporting districts only).
About 47% of all expected maternal complications (20% of pregnancies) were managed by the
health care system at primary or tertiary levels of care. The national target for obstetric complications management is 60% by 2007 and 80% by 2010. Central Java is below national expectations
on this indicator.
Management of neonatal complications (estimated to be 25% of newborn) appears to be even
lower. While the national target for 2007 is 60%, increasing to 80% in 2010, Central Java reports
managing about 5% of all expected neonatal complications.

Maternal and Neonatal Deaths


Provincial Reproductive Health & MPS Profile of Indonesia

103

CENTRAL JAVA
There were 631 maternal deaths reported in Central Java in 2005, nearly 15% of all reported maternal deaths in Indonesia. The estimated maternal
mortality ratio (MMR) is 106 / 100,000 live births.
This is smaller than national estimates (MMR=230,
range 58 to 440, WHO/UNICEF/UNFPA, 2000 or
MMR=307, IDHS, 2002/3) and suggests under-reporting, though the MMR in Central Java may indeed be lower than the national average.

HOSPITAL CASES
Causes of Maternal Deaths, 2005
bleeding
36%
other /
unknown
36%

eclampsia
18%
infection
10%

The predominant cause of maternal death


Maternal Mortality Ratio 2001-05
(deaths / 100,000 reported newborn)
in Central Java is bleeding, though eclampsia plays a significant role. Key interven110
106
105
105
tions to reduce risk of hemorrhage should
100
be emphasized (iron deficiency anemia
95
91
91
control, trained midwives, appropriate use
90
90
rd
of oxytocics in active management of 3
85
stage as per national policy, access to
80
safe blood transfusion/fluid replacement).
2001
2002
2003
2004
2005
Women with signs or symptoms of hypertensive disorders of pregnancy should be
treated properly and actively referred to specialist care at a hospital, since early delivery by c-section is the most effective measure to prevent progression to eclampsia and death.
It should be noted that more than one-third (36%) of all maternal deaths are not attributed to
any immediate cause of death. More importance should be attached to correctly diagnosing
and recording causes of maternal deaths in order to more closely track progress toward effective management of obstetric complication and identify potential interventions to reduce maternal
mortality.
The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based
on reported data, Central Java has a neonatal mortality rate of only 6.6 compared to a national
estimate of 18 neonatal deaths per 1000 births (WHO, 2006). The IDHS 2002/2003 reported the
neonatal mortality rate is 25/1000 birhts. Therefore, it is unlikely that the Central Java data on
neonatal mortality are accurate enough to utilize as an outcome indicator.
The ratio of early to late neonatal deaths is consistent with estimates for Indonesia. More than
80% of all neonatal deaths in Central Java occurred in the first 7 days of life suggesting the
importance of improving quality and access to pregnancy care, safer delivery and emergency
neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis,
and management of low birth weight newborn).
The reported stillbirth rate is 5.1 / 1000 estimated deliveries in Central Java compared to the
national estimate of 17.

Hospital Management of Maternal and Neonatal Complications

104

OB/GYN cases treated at hospital


(includes normal deliveries)
Complicated OB/GYN cases
treated at hospital 2
Case fatality rate 3
Hospital admissions due to abortion
Caesarean sections

Number % of Hospital Cases

% Coverage
(reported pregnancies) 1
4.6% of all pregnancies

31,052

--

17,505

56.4

--

347

1.98

63.4% of reported maternal


deaths (547 in 2004) occurred in hospital

5793

18.7

--

9747

31.4

1.6% of all deliveries

Denominators from 2004 data were pregnancies: 671,443; deliveries: 620,366.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Reported data from hospitals in Central Java indicate that nearly 5% of all deliveries occur in
hospital. More than one-half of these deliveries
are classified as complicated.
Obstetric Complications at Hospital 2004
The case fatality rate for complications among
hospital deliveries at 2.0% (WHO>1%) and nearly
63% of all reported maternal deaths occurred in
the hospital.

abortion
33%

other /
unknown
46%

eclampsia
9%

bleeding
10%

infection
2.4%

Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
Nearly 19% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion practices in Central Java. About 31% of all deliveries in hospital are by caesarean section.
The c-section rate over all deliveries in the province is 1.6% and suggests that there are some
women delivering outside of hospitals who would have had better outcomes if delivered by csection. Internationally, from 5-15% of women are expected to require delivery by c-section for
optimal maternal/neonatal outcome.

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or

Provincial Reproductive Health & MPS Profile of Indonesia

CENTRAL JAVA
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.
4. Investigate the reason behind relatively low ANC1 coverage. Why do so many women never access antenatal care? Investigate the reasons behind the difference between ANC4
and ANC1 rates of attendance. Who are these women entering the system but not being
retained? Why do they drop out?
5. Increase further the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Improve management of obstetric and neonatal complications.
8. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
9. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


10. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
11. Review systems for documenting and counting total deliveries, and live births to ensure
these important denominators are counted accurately, and not under-reported.
12. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.
13. Given the predominance of private hospitals in Central Java, investigate data quality and
completeness at private versus public hospitals to identify gaps or weaknesses (i.e. no private hospital reported CEONC certification, what proportion of obstetric cases are handled
in private vs. public ).

women who receive medical care in districts where they do not reside.
COVERAGE OF MIDWIFE PERSONNEL
Total reported delivDistrict
eries
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

Kota Salatiga
Kota Semarang
Semarang
Kendal
Demak
Grobogan
Pati
Kudus
Jepara
Rembang
Blora
Kota pekalongan
Kota Tegal
Batang
Pemalang
Pekalongan
Tegal
Brebes
Banjarnegara
Cilacap
Purbalingga
Banyumas
Kota Magelang
Temanggung
Wonosobo
Magelang
Purworedjo
Kebumen
Kota Surakarta
Boyolali
Sragen
Sukoharjo
Krnganyar
Wonogiri
Klaten

TOTAL

3,056
26,365
17,695
18,360
25,827
23,540
19,482
15,404
22,846
9,623
16,289
6,748
6,004
13,522
23,434
16,529
28,032
43,099
16,857
30,484
17,482
30,124
2,453
11,536
16,658
22,594
10,668
24,174
10,781
16,435
17,223
13,939
13,377
14,452
18,907

623,999

Total APN midwives

0
0
0
0
0
0
122
0
0
166
0
0
0
0
219
0
0
194
1
0
0
0
0
31
0
0
0
0
0
0
102
0
0
0
0
835
1 / 747 deliveries)

Total LSS midwives


0
0
0
0
179
0
149
72
0
119
0
0
0
0
129
0
0
132
129
0
0
0
0
49
0
0
0
0
0
0
163
0
0
0
0
1121
1 / 557 deliveries)

14. Review systems for documenting and counting total pregnancies, deliveries, and live births
to ensure these important denominators are as accurate and consistent as possible. Investigate how data of vital events and health service visits are recorded and reported for

Provincial Reproductive Health & MPS Profile of Indonesia

105

CENTRAL JAVA
BEONC UNMET NEED ACCORDING TO STANDARDS
Total UnWHO rec#
Unmet
Total popumet Need Pop. / ommended
District
BEONC
need
lation
(MOH:
BEONC coverage
in 2005
(WHO)
4 / district)
(1 / 125,000)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

Kota Salatiga
Kota Semarang
Semarang
Kendal
Demak
Grobogan
Pati
Kudus
Jepara
Rembang
Blora
Kota pekalongan
Kota Tegal
Batang
Pemalang
Pekalongan
Tegal
Brebes
Banjarnegara
Cilacap
Purbalingga
Banyumas
Kota Magelang
Temanggung
Wonosobo
Magelang
Purworedjo
Kebumen
Kota Surakarta
Boyolali
Sragen
Sukoharjo
Krnganyar
Wonogiri
Klaten
TOTAL

106

146,467
1,389,416
879,785
882,145
1,024,934
1,299,175
1,218,264
738,410
1,034,799
582,037
826,702
264,634
244,426
692,519
1,316,977
838,276
1,429,345
1,763,581
886,961
1,641,849
846,924
1,501,370
119,400
694,892
759,018
1,142,467
709,397
1,193,850
485,501
925,722
859,986
807,635
831,248
1,120,485
1,287,990
32,386,587

0
1
7
4
5
5
1
4
5
16
0
1
0
4
4
3
4
9
5
6
5
8
0
5
3
6
5
3
0
1
0
3
0
5
10
138

4
-3 1,389,416
0
125,684
0
220,536
0
204,987
0
259,835
3 1,218,264
0
184,603
0
206,960
0
36,377
4
-3
264,634
4
-0
173,130
0
329,244
1
279,425
0
357,336
0
195,953
0
177,392
0
273,642
0
169,385
0
187,671
4
-0
138,978
1
253,006
0
190,411
0
141,879
1
397,950
4
-3
925,722
4
-1
269,212
4
-0
224,097
0
128,799
44
234,685

1
11
7
7
8
10
10
6
8
5
7
2
2
6
11
7
11
14
7
13
7
12
1
6
6
9
6
10
4
7
7
6
7
9
10
259

1
10
0
3
3
5
9
2
3
0
7
0
2
2
7
4
7
5
2
7
2
4
1
1
3
3
1
7
4
6
7
3
7
4
0
132

KEY INDICATORS AND NATIONAL TARGETS

Central Java
2001

2005 *

ANC1 (K1)

87

88

ANC4 (K4)

75

SBA deliveries

National Target
2007

2010

79

84

95

67

77

82

90

Not reported

85

83

90

31

38.5

Obstetric complications managed

Not reported

47.1

60

Neonatal complications managed

Not reported

5.3

60

Caesarian section rate (% of hospital deliveries)

27

31 *

Caesarian section rate (% of reported deliveries)

1.9

1.6 *

Hospital OB/GYN cases as % of all pregnancies

6.8

4.6 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

91

106

Postpartum / Neonatal visit (KN1)


Risk detection of pregnant women by community

* c-sections and hospital cases from 2004 data.

Provincial Reproductive Health & MPS Profile of Indonesia

80

YOGYAKARTA
The total population of Yogyakarta (DIY) is 3.3 million,
accounting for 1.5% of the total population in Indonesia,
and nearly 3% of the population in Java. DIY is divided
into 5 districts (4 kabupaten + 1 kota [cities]) with a total
of 438 villages. The capital is Yogyakarta city.
DIY has a much higher urban population (64%) and
slightly higher poor population (19%), compared to the
national average. Adult female literacy is lower than the
national rate at 80%.

GEOGRAPHY

Total land area (km2)


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

3133
5
4
1
78
438

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

The total fertility rate (1.9) and crude birth rate (16.9) are much lower than the national average.
The modern contraceptive prevalence rate is higher (63%) and the percentage of young women
who have begun childbearing is nearly half the national average (5.9%).
Among all contraceptive users, predominant methods used include injection (30%), IUD (26%),
traditional methods (17%), oral contraceptives (10%) and tubal ligation/vasectomy (9%). Condom
use for contraception is the highest in the country (5%).
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

Yogyakarta
3,340,438
64
19
80
1030
Male: 70
Female: 74
1.00
783,000 3
1.9
16.9
5.9
63.2
4.8

National

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

Health Facilities
DIY reports having 25 hospitals total; 6 public and
19 private. There is excellent coverage of specialists in public hospitals, but only about half of all private hospitals report having specialists on staff.
All public hospitals (only 6) are certified as providers of Comprehensive Emergency Obstetric and
Neonatal Care (CEONC) with at least one per district. Some private hospitals may provide CEONC
service, but there are no data reported from private
hospitals on this indicator.
2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

19

Hospitals with CEONC 1

Not reported

In-hospital OBGYN

27

10

In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in
Puskesmas
Puskesmas with bed

37

--1 CEONC hospital / district


>1 / district
<1 / 500,000 pop.
(WHO minimum standard:
one / 500,000 pop.)
1 / 1398 pregnant
-women
-1 / 1045 newborn

117

One PHC / 30,000 pop.

1 / 28,551 pop.

117

--

--

30

--

26% of all puskesmas


13% of all puskesmas

4 / district
Puskesmas BEONC

15

(WHO minimum standard:


One / 125,000 pop.)

Average 3/district; 0 of
5 districts have none
1 / 222,696 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.

Provincial Reproductive Health & MPS Profile of Indonesia

107

YOGYAKARTA
DIY has 117 puskesmas (primary health centers) with as many puskesmas-based general practitioners (117). One-quarter (26%) of all puskesmas have beds for in-patient care.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 15 puskesmas (13%) report having received training and certification in Basic Emergency
Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO) recommended standard for BEONC facilities is 1 per every 125,000 people. Indonesia has adopted this
indicator, but translated it to mean at least four BEONC facilities for each district.
There are 2-3 BEONC facilities per district and twice the population supported by each BEONC
than recommended. For every district to have 4 BEONC, an additional 7 would be required.
However, given the population size of DIY, the recommended number of BEONC facilities is 27,
or 11 more than currently reported.
This goal would be almost reached if the facilities of each puskesmas with a bed could be upgraded to BEONC level. The cost per puskesmas team (3 persons) to be trained in BEONC is
9.3 million (3.1 per person).

Health Personnel
HEALTH PERSONNEL
2001
2005
% Change
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general
practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in LSS
Total TBA
Trained TBA
TBA with kit
1

Not reported
Not reported

37
45

---

252

287 1

14%

211

Not reported

--

682

868

127%

158

114

28%

117
0
Not reported
120
Not reported
0
1348
Not reported
1293
1029
1126
Not reported

---- 24%
--

1 / 11,639 population

Primary Health Care Indicators


DENOMINATORS
FOR KEY INDICATORS

Number

Ratio of reported /
estimated 1

Reported pregnancies

51,736

1.55% of total population

82.6

Reported deliveries

49,678

96.0% of reported pregnancies

83.8

Reported newborn

47,045

94.7% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in DIY of 16.9 (BPS, 2000), the reported pregnancies are significantly
lower (17%) than the estimated pregnancies, and reported deliveries are similarly lower (16%)
than estimated deliveries. However, the proportion of deliveries to pregnancies, and newborn
to deliveries is valid and consistent with the country overall, suggesting that the reported events
are reasonably accurate in relation to one-another, though they may all be under-counted. Other
likely explanations for this lower number of actual pregnancies, deliveries and newborn events
compared to expected number may be that the crude birth rate in DIY is even lower than estimated or the population is lower than reported.

1 / 3848 population
26% of villages have
village midwife
-14% midwives
----

Bantul district reported 441 GPs in 2003 and 2005 (other years, data not reported), but only 43 GPs in 2001. This was assumed to be a data entry error and was corrected to only 44 GPs.

On average, there is one Ob/Gyn specialist for every 90,000 population, and one pediatrician
for every 74,000 population. Coverage of GPs exceeds the recommended standard. However,
population coverage of midwives is below standard, despite a small increase in midwives since

108

2001. An additional 245 midwives would be required to meet the standard of 1/3000 population.
Only 1 in 4 (26%) of all villages report having a midwife living in the village, and this coverage has
declined nearly 30% since 2001. Only 1 in 7 (14%) of all midwives has received APN training,
and none are reported to have received BEONC training.

Antenatal Care Coverage


Among reported pregnancies, 98% of the women
attended at least one antenatal visit (ANC1).
This drops to 82% coverage of 4 total antenatal
visits (ANC4), which is close to the 2007 target of
84%. Although ANC1 coverage is very good, the
difference between ANC4 and ANC1 shows that
nearly 8,500 women who have accessed antenatal care once do not obtain the minimum standard
of 4 antenatal visits. These women are either not
adhering to the recommended antenatal schedule or are accessing ANC too late to reach 4 visits.
Quality of care, community awareness, and logistical accessibility factors likely account for these

Provincial Reproductive Health & MPS Profile of Indonesia

YOGYAKARTA
missed opportunities. Fewer than 1000 pregnant women never accessed any antenatal care.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in DIY. More than 97% of women report having an abdominal examination,
weight and blood pressure measured, and received iron tablets. However, only 36% report being
informed of signs of pregnancy complications and only 41% gave a blood sample. Although DIY
has one of the best quality indicators for antenatal care compared to the country overall, these
last two indicators represent critical components of antenatal care and should be improved upon
further.
There is some variation in reported antenatal coverage across districts. Yogyakarta city reports
more than 100% ANC1 attendance while Bantul and Gunung Kidul report coverage in the mid80%. Data were not adjusted for over-reporting, however, since DIY is a predominantly urban
province and population migration across district borders for health services is likely to be common.

Skilled Birth Attendance


More than four out of five (83%) of all reported deliveries are attended by a skilled health professional
(SBA=skilled birth attendant). Although the indicator already exceeds the national target for 2007,
there are still more than 8,600 deliveries unattended
in DIY.
Nearly twice as many women in DIY deliver in a
health facility compared to the national
average. Nearly 19% deliver at a public
facility and over 52% deliver at a private
facility. Only 27% deliver at home. More
than twice the number of women deliver
with a doctor (26%) compared to only 11%
in the country overall. Attendance with a
nurse/midwife (59%) is similar to the national average, but half as many women
deliver with a TBA (15%) compared to
over 30% in Indonesia overall.
Variation in coverage of antenatal care
and skilled birth attendance do not show
a consistent trend toward higher coverage
between 2002 and 2004; the years 2001
and 2005 show the highest coverage.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that nearly 92% of all births
are officially registered in DIY, the highest among
all provinces in Indonesia. DIY is a leader in
this area and could possibly provide assistance
to other provinces to increase the proportion of
births registered in Indonesia overall.
Over 86% of all reported newborn attend the
first and second neonatal visits (KN1, KN2).
KN1 data was not reported. The IDHS
found higher rates of postpartum/neonatal care attendance, and lower rates
of missing care altogether (<5%).

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate of pregnant
women detected as at risk by the community, including cadres, TBAs or other
lay persons (i.e. non-health professionals). Indonesia adopted that 20% of
all pregnant women will need medical
attention during pregnancy or delivery,
or over 10,000 pregnant women in DIY
annually (20% of all pregnant women
reported).

Provincial Reproductive Health & MPS Profile of Indonesia

109

YOGYAKARTA
Overall, 43% of this total number of women were detected as being at risk by a health provider.
DIY did not report the rate of community detection of risk.
About 26% of all expected maternal complications (20% of pregnancies) were managed by the
health care system at primary or tertiary levels of care. The national target for obstetric complications management is 60% by 2007 and 80% by 2010. DIY is far below national expectations on
this indicator.
Management of neonatal complications (estimated to be 25% of newborn born) appears to be
even lower. While the national target for 2007 is 60%, increasing to 80% in 2010, DIY reports
managing less than 3% of all expected neonatal complications.

Maternal and Neonatal Deaths


There were 39 maternal deaths reported in
DIY in 2005, nearly 1% of all reported maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 83 / 100,000 live
births. This is smaller than national estimates
(MMR=230, range 58 to 440, WHO/UNICEF/
UNFPA, 2000 or MMR=307, IDHS, 2002/3)
and suggests under-reporting, though the
MMR in DIY may indeed be lower than the
national average.

The ratio of early to late neonatal deaths cannot be calculated because neonatal mortality by age
was not reported. However, about three-quarters of all neonatal deaths in Indonesia occur in the
first 7 days of life suggesting the importance of improving quality and access to pregnancy care,
safer delivery and emergency neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis, and management of low birth weight newborn).
The reported stillbirth rate is 3.9 / 1000 estimated deliveries in DIY compared to the national
estimate of 17.

Hospital Management of Maternal and Neonatal Complications


Causes of Maternal Deaths, 2005
other /
unknown
56%
bleeding
23%

infection
3%

eclampsia
18%

Reported data from hospitals in DIY indicate that over 7% of all deliveries occur in hospital. Onethird (32%) of these deliveries are classified as complicated.
The case fatality rate for complications among hospital deliveries is at 1.9% (WHO>1%) and
nearly 82% of all reported maternal deaths occurred in the hospital.
Number

% of Hospital Cases

% Coverage
(reported pregnancies) 1

OB/GYN cases treated at hospital (includes normal deliveries)

4235

--

7.4% of all pregnancies

Complicated OB/GYN cases treated at


hospital 2

1409

33.3

--

Case fatality rate 3

27

1.92

81.8% of reported maternal


deaths (33 in 2004) occurred
in hospital

Hospital admissions due to abortion

606

14.3

--

Caesarean sections

1373

32.4

2.5% of all deliveries

HOSPITAL CASES
Maternal Mortality Ratio, 2001-05
(deaths / 100,000 reported newborn)

The predominant cause of maternal death in


94
94
100
90
83
90
DIY is bleeding, though eclampsia plays a sig80
64
70
nificant role. Key interventions to reduce risk
60
50
of hemorrhage should be emphasized (iron
40
30
deficiency anemia control, trained midwives,
20
10
appropriate use of oxytocics in active man0
rd
2001
2002
2003
2004
2005
agement of 3 stage as per national policy,
access to safe blood transfusion/fluid replacement). Women with signs or symptoms of hypertensive disorders of pregnancy should be treated
properly and actively referred to specialist care at a hospital, since early delivery by c-section is
the most effective measure to prevent progression to eclampsia and death.
It should be noted that more than one-half (56%) of all maternal deaths are not attributed to
any immediate cause of death. More importance should be attached to correctly diagnosing
and recording causes of maternal deaths in order to more closely track progress toward effective management of obstetric complication and identify potential interventions to reduce maternal
mortality.
The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based
on reported data, DIY has a neonatal mortality rate of only 4.7 compared to a national estimate

110

of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the DIY data
on neonatal mortality are accurate enough to utilize as an outcome indicator. According to IDHS
2002/2003, the neonatal mortality rate is 17/1000 birhts. This province need some effort to achive
the 2009 target, 15/1000 briths.

Denominators from 2004 data were pregnancies: 57,212; deliveries: 55,536.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or
community preparedness in recognizing risk and
making timely referrals. The status of maternal
and neonatal mortality audits is not reported in the

Provincial Reproductive Health & MPS Profile of Indonesia

YOGYAKARTA
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
Over 14% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion practices in DIY. About 32% of all deliveries in hospital are by caesarean section. The csection rate over all deliveries in the province is 2.5% and suggests that there are some women
delivering outside of hospitals who would have had better outcomes if delivered by c-section.
Internationally, from 5-15% of women are expected to require delivery by c-section for optimal
maternal/neonatal outcome.

Recommendations

all districts before finalizing annual data submissions.


11. Given the predominance of private hospitals in DIY, investigate data quality and completeness at private versus public hospitals to identify gaps or weaknesses (i.e. no private hospital reported CEONC certification, what proportion of obstetric cases are handled in private
vs. public ).
12. Review systems for documenting and counting total pregnancies, deliveries, and live births
to ensure these important denominators are as accurate and consistent as possible. Investigate how data of vital events and health service visits are recorded and reported for
women who receive medical care in districts where they do not reside.
BEONC UNMET NEED ACCORDING TO STANDARDS

Coverage of health personnel and service inputs


1. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
2. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife. With relatively good rates of
SBA coverage, an important agenda for DIY should be to aggressively upgrade the technical skills of those attendants and ensure adequate access to well-prepared facilities.
3. Increase further the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
4. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
5. Improve management of obstetric and neonatal complications.
6. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.

District
1
2
3
4
5

Kota Yogyakarta
Bantul
Kulon Progo
Gunung Kidul
Sleman
TOTAL

WHO rec#
Total Unmet
Unmet
Total popPop. / ommended
BEONC Need (MOH:
need
ulation
BEONC coverage
in 2005 4 / district)
(WHO)
(1 / 125,000)
508,285
783,060
423,862
745,122
880,109

2
6
1
2
4

2
0
3
2
0

254,143
130,510
423,862
372,561
220,027

4
6
3
6
7

2
0
2
4
3

3,340,438

15

222,696

27

11

COVERAGE OF MIDWIFE PERSONNEL


Total reported
District
Total APN midwives Total LSS midwives
deliveries
1
2
3
4
5

Kota Yogyakarta
Bantul
Kulon Progo
Gunung Kidul
Sleman

TOTAL

5,746
12,583
5,372
10,564
15,413

65
22
11
12
10

0
0
0
0
0

49,678

120
(1 / 414 deliveries)

7. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


8. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
9. Review systems for documenting and counting total deliveries, and live births to ensure
these important denominators are counted accurately, and not under-reported.
10. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from

Provincial Reproductive Health & MPS Profile of Indonesia

111

YOGYAKARTA
KEY INDICATORS AND NATIONAL TARGETS

Yogyakarta
2001

2005 *

ANC1 (K1)

96

98

ANC4 (K4)

76

SBA deliveries

National Target
2007

2010

82

84

95

84

83

82

90

Postpartum / Neonatal visit (KN1)

92

86

83

90

Risk detection of pregnant women by community

2.3

Not reported

Obstetric complications managed

Not reported

25.5

60

80

Neonatal complications managed

Not reported

2.7

60

80

Caesarian section rate (% of hospital deliveries)

27

32 *

Caesarian section rate (% of reported deliveries)

5.7

2.5 *

Hospital OB/GYN cases as % of all pregnancies

19.7

7.4 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

90

83

* c-sections and hospital cases from 2004 data.

112

Provincial Reproductive Health & MPS Profile of Indonesia

EAST
JAVA

he total population of East Java is over 36 million,


accounting for nearly 17% of the total population
in Indonesia, and 28% of the population in Java.
East Java is divided into 38 districts (29 kabupaten + 9 Kota [cities]) with a total of 8484 villages. The
capital is Surabaya.
East Java has a similar urban population (49%) and higher
poor population (21%) compared to the national average.
Adult female literacy is lower than the national rate at 79%.
SOCIAL DEMOGRAPHY
Total population (2005)

Percent urban population (2005)

Percent poor population (2004) 2


Adult female literacy rate (2004)

Population density (km sq.; 2005)


Life expectancy at birth (2002)

Annual growth rate (2000-2005) 2


Women of reproductive age
Total fertility rate / 1000 women

GEOGRAPHY
Total land area (km2)
Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

46,690
38
29
9
657
8484

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

National

36,493,775

220,659,431

49

48

21

17

79

87

742

116

Male: 64
Female: 68
0.45
8,554,140

45

109

Male: 64
Fe male: 68

Hospitals with CEONC 1

42

Not reported

1.34

In-hospital OBGYN
In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in
Puskesmas
Puskesmas with bed

135
118

58
57

51,732,453
2.6

17.4

22.0

10.9

10.4

Modern contraceptive prevalence (%) 6

63.2

56.7

Unmet need for contraception (%) 6

5.6

8.6

Crude birth rate / 1000 pop. (2000)

Percentage of women 15-19 who have begun childbearing

2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

2.1

Health Facilities
East Java reports 154 hospitals, over 70% private. There appears to be excellent staffing of
specialists in public hospitals, bus fewer specialists in private hospitals.

East Java

have begun childbearing (10.9%) is similar to the national average. Among all contraceptive users, most
women choose injection (40%), oral contraceptives
(20%) or IUD (16%). Other methods include tubal ligation/vasectomy (9%), implants (8%), traditional methods (6%), or condoms (only 1%).

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3

929

One PHC / 30,000 pop.

1 / 39,283 pop.

971

--

--

306

--

33% of all puskesmas


11% of all puskesmas

4 / district

Average 2-3/district; 11
of 38 districts report
none

1
2

Puskesmas BEONC

The total fertility rate (2.1) and crude birth rate (17.4) are lower than the national average. The
modern contraceptive prevalence rate is higher (63%) and the percentage of young women who

--1 CEONC hospital / district


>1 / district
(WHO minimum standard: <1 / 500,000 pop.
one / 500,000 pop.)
-1 / 3617 pregnant women
-1 / 3627 newborn

102

(WHO minimum standard:


One / 125,000 pop.)

1 / 357,782 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.

Almost all (42) public hospitals are certified as providers of Comprehensive Emergency Obstetric

Provincial Reproductive Health & MPS Profile of Indonesia

113

EAST JAVA
and Neonatal Care (CEONC) with at least one per district. There may even be more CEONC
providers among private hospitals, but this indicator is not reported.
East Java has 929 puskesmas (primary health centers) with nearly as many puskesmas-based general practitioners (971). One-third (33%) of puskesmas have beds for in-patient care.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 102 puskesmas (11%) report having received training and certification in Basic Emergency
Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO) recommended standard for BEONC facilities is 1 for every 125,000 people. Indonesia has adopted this
indicator, but translated it to mean at least four BEONC facilities for each district.
Most districts report at least one BEONC facility, ranging from 1-8 per district. However, six
kabupaten report zero (Tulungagung, Banyuwangi, Bondowoso, Mojokerto, Madiun, Bangkalan) and 5 kota report none (see BEONC unmet need table at end of this profile) but this lack
of coverage in cities is likely a reporting error. On average, nearly three times the population than
recommended is supported by each BEONC. For every district to have 4 BEONC, an additional
102 would be required. However, given the population size of East Java, the recommended minimum number of BEONC facilities is 292. Taking into account variation in coverage by population
density, an additional 190 BEONC facilities are recommended.
One immediate step would be to upgrade each puskesmas with a bed to BEONC level, focusing
first on districts currently under-served by BEONC and CEONC facilities. Later efforts could be
continued to reach the WHO recommended number of BEONC facilities in each district. The cost
per puskesmas team (3 persons) to be trained in BEONC is IDR 9.3 million (3.1 per person).

Health Personnel
The total number of specialists in East Java has grown since 2001. On average, there is one
Ob/Gyn specialist for every 188,000 population, and one pediatrician for every 203,000 population. Coverage of GPs now is slightly below the recommended standard at 1/35,000. Population
coverage of midwives is well below the standard. An additional 5922 midwives would be required
to meet the standard of 1/3000 population. Only 57% of all villages are reported to have a midwife
living in the village, and this coverage has decreased 10% since 2001. While 43% of all midwives
are APN-trained, only 11% are reported to have received LSS training.

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.
Assuming a crude birth rate in East Java of 17.4 (BPS, 2000), the reported pregnancies are less
than 1% lower that estimated pregnancies and reported deliveries are 4% lower than estimated
deliveries. Total deliveries and live births in all districts appear to be calculated based on an as-

114

DENOMINATORS FOR
KEY INDICATORS
Reported pregnancies
Reported deliveries
Reported newborn

Number

698,177
641,054
634,705

1.91% of total population


91.8% of reported pregnancies
99.0% of reported deliveries

Ratio of reported /
estimated 1
99.1
96.2
--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

sumed proportion of all pregnancies. Deliveries are assumed to be 91.8% of all pregnancies, and
live births are assumed to be 99.0% of all deliveries. These data make it difficult to evaluate the
level of accuracy in reproductive health vital statistics reporting across districts, although the total
number of pregnancies appears to be quite accurate. These multipliers are also different from the
observed relationship between deliveries and pregnancies, and live births and deliveries. Among
all HIS reported pregnancy, delivery and live birth events reported in 2005, the average rate of
deliveries to pregnancies was 94.7 and the average rate of live births to deliveries was 96.3. For
indicator calculation in this profile, reported pregnancies, deliveries and newborn were retained.
HEALTH PERSONNEL
(minimum standard)

2001

2005

%
Change

Coverage

Rows bordered in red are below minimum standard


OB/GYNs

161

194

20%

Pediatricians

161

180

12%

Primary health center general practitioners


(One GP / 30,000 pop.)

1364

1038 1

Nurses trained in ANC

617

698 3

13%

Total midwives
(One / 3000 pop.)

5617 4

6245

11%

1 / 5844 population

Midwives living in the village


(One / village)

5393 4

4856

10%

57% of villages have


village midwife

Midwives with a kit

4600 4

4588

Same

1 / 7954 population

Midwives trained in APN

Not reported

2688

--

43% midwives

Midwives trained in LSS

Not reported

702

--

1 / 51,985 population

Total TBA

15,885

13405

16%

Trained TBA

14,281

1573

89%

12% of all TBA

TBA with kit

11,275

8488

25%

63% of all TBA

Not calcu1 / 35,158 population


lated 2

Ten districts (Kab. Pacitan, Kab. Ponogoro, Kab. Trenggalek, Kab. Tulungagung, Kab. Blitar, Kab. Kediri, Kab. Malang,
Kab. Lumajang, Kab. Jember, Kab. Banyuwangi) did not report this indicator.
2
Change not calculated due to missed reports from 10 of 38 districts. Denominator adjusted change between 2001 and 2005
among reporting districts in both times was 10%.
3
One district (Kab. Sidoarjo) did not report this indicator.
4
Eight districts (Kota Surabaya, Kota Madiun, Kota Probolinggo, Kota Blitar, Kota Kediri, Kota Mojokerto, Koto Malang,
Kota Pasuran) did not report this indicator.
1

Provincial Reproductive Health & MPS Profile of Indonesia

EAST JAVA
Antenatal Care Coverage
Among reported pregnancies, 90% of the women attended at least one antenatal visit (ANC1).
This drops to 77% coverage of 4 total antenatal
visits (ANC4), which is below the 2007 target
of 84%. Although ANC1 coverage is relatively
good, the difference between ANC4 and ANC1
shows that over 90,000 women who have accessed antenatal care once do not obtain the
minimum standard of 4 antenatal visits. These
women are either not adhering to the recommended antenatal schedule or are accessing ANC
too late to reach 4 visits. Quality of care, community awareness, and logistical accessibility
factors likely account for these missed opportunities. Over 72,000 pregnant women never accessed any antenatal care in East Java.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in East Java. More than 98% of women report having an abdominal examination, 93% report having their weight and blood pressure measured, and 88% received iron tablets.
However, only 38% report being informed of signs of pregnancy complications and only 27% report giving a blood sample. These data show that critical components of antenatal care are often
not provided, and the overall quality of antenatal care should be examined more closely.
There is minimal variation in reported antenatal coverage by most districts, however, three districts
reported lower rates of ANC1 and ANC4 compared to the provincial average: Kab. Lamongan (72%
and 70%, respectively), Kota Probolinggo (76% and 49%), and Kota Pasuran (69% and 34%).

Skilled Birth Attendance

and a lower proportion of women report being attended by a TBA (17%) compared to the
national estimates. These estimates do not
provide a breakdown between hospital and
non-hospital deliveries.
Three districts, Bangkalan (65%), Sumenap
(65%), Kota Pasuruan (50%), report lower
skilled birth attendant coverage rates compared to the provincial average. Four districts
were excluded from the SBA coverage calculation because they reported from 112 195%
coverage.
There is no consistent trend toward increasing
or decreasing antenatal care or SBA coverage
in East Java from 2001-05.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that nearly 70% of all births are officially registered in East Java, higher than
the national average. About 85% of all reported newborn attend the first and second neonatal
visits (KN1, KN2) and 2% attend KN1 only. The IDHS found higher rates of postpartum/neonatal
care attendance, and lower rates of missing care altogether (8%).
Three districts were excluded from the postpartum/neonatal coverage calculation because they
reported from 113 200% coverage.

More than 4 out of 5 (82%) of all reported deliveries are attended by a skilled health professional
(SBA=skilled birth attendant). The national target
for skilled birth attendance is 82% by 2007 and
90% by 2010. Despite meeting the national target,
in a heavily populated province like East Java, this
leaves more than 112,000 women delivering without any skilled birth attendant.
The IDHS found that a smaller proportion of
women in East Java delivered at home (38%)
compared to the national average of nearly 60%.
Over 60% of women delivered at a health facility (50% private, 10% public), far higher than the
national estimate of only 40%. A higher proportion of women in East Java report being attended
by an OB/Gyn (18%) or nurse/midwife (62%)

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate
of pregnant women detected as at risk by the community, including cadres, TBAs or other lay
persons (i.e. non-health professionals). Indonesia adopted that 20% of all pregnant women will
need medical attention during pregnancy or delivery, or nearly 140,000 pregnant women in East
Java annually (20% of all pregnant women reported).

Provincial Reproductive Health & MPS Profile of Indonesia

115

EAST JAVA
Overall, only 29% of this total number of
women was detected as being at risk by
community members and 77% were detected
by a health provider (denominator adjusted,
applicable to reporting districts only).

tive management of obstetric complication and identify potential interventions to reduce maternal
mortality.

About 65% of all expected maternal complications (20% of pregnancies) were managed
by the health care system at primary or tertiary levels of care. The national target for
obstetric complications management is 60%
by 2007 and 80% by 2010. East Java is far below national expectations on this indicator.
Management of neonatal complications (estimated to be 25% of newborn born) appears to be
even lower. While the national target for 2007 is 60%, increasing to 80% in 2010, East Java
reports managing about 3% of all expected neonatal complications.

Maternal and Neonatal Deaths


There were 413 maternal deaths reported in
East Java in 2005, nearly 10% of all reported
maternal deaths in Indonesia. The estimated
maternal mortality ratio (MMR) is 65 / 100,000
live births. This is far smaller than national
estimates (MMR=230, range 58 to 440, WHO/
UNICEF/UNFPA, 2000 or MMR=307, IDHS,
2002/3) and suggests under-reporting,
though the MMR in East Java may indeed
be lower than the national average.

Causes of Maternal Deaths, 2005


other /
unknown
37%

infection
10%

bleeding
37%

eclampsia
16%

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)

74
72
72
The predominant cause of maternal death
72
70
in East Java is bleeding, though eclamp68
65
65
sia plays a significant role. Key interven66
64
62
tions to reduce risk of hemorrhage should
62
60
be emphasized (iron deficiency anemia
58
56
control, trained midwives, appropriate use
2001
2002
2003
2004
2005
of oxytocics in active management of 3rd
stage as per national policy, access to safe
blood transfusion/fluid replacement). Women with signs or symptoms of hypertensive disorders
of pregnancy should be treated properly and actively referred to specialist care at a hospital, since
early delivery by c-section is the most effective measure to prevent progression to eclampsia and
death.

It should be noted that more than one-third (37%) of all maternal deaths are not attributed to
any immediate cause of death. More importance should be attached to correctly diagnosing
and recording causes of maternal deaths in order to more closely track progress toward effec-

116

The number of reported stillbirths and neonatal deaths indicate serious under-reporting. Based
on reported data, East Java has a neonatal mortality rate of only 3.0 compared to a national estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the East
Java data on neonatal mortality are accurate enough to utilize as an outcome indicator. According
to IDHS 2002/2003, the neonatal mortality rate is 28/1000 birhts. This province need high effort to
achive the 2009 target, 15/1000 briths.
The ratio of early to late neonatal deaths is consistent with estimates for Indonesia. More than
70% of all neonatal deaths in East Java occurred in the first 7 days of life suggesting the importance of improving quality and access to pregnancy care, safer delivery and emergency neonatal
care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis, and management of low birth weight newborn).
The reported stillbirth rate is 5.1 / 1000 estimated deliveries in East Java compared to the national
estimate of 17.

Hospital Management of Maternal and Neonatal Complications


HOSPITAL CASES
OB/GYN cases treated at hospital
(includes normal deliveries)
Complicated OB/GYN cases
treated at hospital 2
Case fatality rate 3
Hospital admissions due to abortion
Caesarean sections

Number % of Hospital Cases

% Coverage
(reported pregnancies) 1

27,199

--

3.9% of all pregnancies

13,353

49.1

--

156

1.17

39.9% of reported maternal


deaths (393 in 2004) occurred in hospital

4270

15.7

--

10,336

38.0

1.7% of all deliveries

Denominators from 2004 data were pregnancies: 692,930; deliveries: 607,319.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Reported data from hospitals in East Java indicate


that nearly 4% of all deliveries occur in hospital.
Almost one-half (49%) of these deliveries are classified as complicated.
The case fatality rate for complications among hospital deliveries is at 1.2% (WHO>1%) and nearly
40% of all reported maternal deaths occurred in the
hospital.

Provincial Reproductive Health & MPS Profile of Indonesia

EAST JAVA
Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
Nearly 16% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion practices in East Java. About 38% of all deliveries in hospital are by caesarean section.
The c-section rate over all deliveries in the province is 1.7% and suggests that there are women
delivering outside of hospitals who would have had better outcomes if delivered by c-section.
Internationally, from 5-15% of women are expected to require delivery by c-section for optimal
maternal/neonatal outcome.

9. Review systems for documenting and counting total pregnancies, deliveries, and live births
to ensure these important denominators are as accurate and consistent as possible. Investigate how data of vital events and health service visits are recorded and reported for
women who receive medical care in districts where they do not reside.

KEY INDICATORS AND NATIONAL TARGETS

Coverage of health personnel and service inputs


1. Increase the number of BEONC facilities over the province. Ensure minimum standards of
distribution of BEONC facilities across all districts, and correlation with population size.
2. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.

National Target

2001

2005 *

2007

2010

ANC1 (K1)

92

90

ANC4 (K4)

77

77

84

95

SBA deliveries

81

82

82

90

Not reported

87

83

90

3.4

28.7

Obstetric complications managed

Not reported

65.3

60

80

Neonatal complications managed

Not reported

2.6

60

80

Caesarian section rate (% of hospital deliveries)

31.1

38.0 *

Caesarian section rate (% of reported deliveries)

2.2

1.7 *

Hospital OB/GYN cases as % of all pregnancies

6.4

3.9 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

72

65

Postpartum / Neonatal visit (KN1)


Risk detection of pregnant women by community

Recommendations

East Java

* c-sections and hospital cases from 2004 data.

3. Improve management of obstetric and neonatal complications.


4. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
5. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


6. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
7. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.
8. Given the predominance of private hospitals in East Java, investigate data quality and completeness at private versus public hospitals to identify gaps or weaknesses (i.e. no private
hospital reported CEONC certification, what proportion of obstetric cases are handled in
private vs. public ).

Provincial Reproductive Health & MPS Profile of Indonesia

117

EAST JAVA
BEONC UNMET NEED ACCORDING TO STANDARDS
Total UnWHO recom#
Unmet
Total popmet Need Pop. / mended cov
District
BEONC
need
ulation
(MOH:
BEONC
erage
in 2005
(WHO)
4 / district)
(1 / 125,000)
1 Kab. Pacitan
2 Kab. Ponorogo
3 Kab. Trenggalek
4 Kab. Tulungagung
5 Kab. Blitar
6 Kab. Kediri
7 Kab. Malang
8 Kab. Lumajang
9 Kab. Jember
10 Kab. Banyuwangi
11 Kab. Bondowoso
12 Kab. Situbondo
13 Kab. Probolinggo
14 Kab. Pasuruan
15 Kab. Sidoarjo
16 Kab. Mojokerto
17 Kab. Jombang
18 Kab. Nganjuk
19 Kab. Madiun
20 Kab. Magetan
21 Kab. Ngawi
22 Kab. Bojonegoro
23 Kab. Tuban
24 Kab. Lamongan
25 Kab. Gresik
26 Kab. Bangkalan
27 Kab. Sampang
28 Kab. Pamekasan
29 Kab. Sumenep
Sub-total Kabupaten

533,900
862,196
677,303
970,429
1,104,905
1,478,660
2,368,308
1,012,728
2,298,189
1,545,648
710,593
627,086
1,056,604
1,447,593
1,680,711
966,283
1,191,154
1,015,601
656,968
621,261
837,383
1,221,116
1,108,742
1,233,972
1,073,747
850,679
792,843
723,528
1,016,935
31,685,065

2
2
8
0
6
4
5
4
7
0
0
3
2
3
4
0
6
1
0
3
5
8
6
5
2
0
5
5
1
97

30
31
32
33
34
35
36
37
38

255,465
124,939
804,570
204,077
180,714
114,871
170,048
2,775,199
178,827
4,808,710
36,493,775

0
0
0
1
2
1
1
0
0
5
102

118

Kota. Kediri
Kota. Blitar
Kota. Malang
Kota. Probolinggo
Kota. Pasuruan
Kota. Mojokerto
Kota. Madiun
Kota. Surabaya
Kota. Batu
Sub-total Kota
GRAND TOTAL

2
266,950
2
431,098
0
84,663
4
-0
184,151
0
369,665
0
473,662
0
253,182
0
328,313
4
-4
-1
209,029
2
528,302
1
482,531
0
420,178
4
-0
198,526
3 1,015,601
4
-1
207,087
0
167,477
0
152,640
0
184,790
0
246,794
2
536,874
4
-0
158,569
0
144,706
3 1,016,935
41
326,650

4
7
5
8
9
12
19
8
18
12
6
5
8
12
13
8
10
8
5
5
7
10
9
10
9
7
6
6
8
253

2
5
0
8
3
8
14
4
11
12
6
2
6
9
9
8
4
7
5
2
2
2
3
5
7
7
1
1
7
159

4
4
3
3
2
3
3
4
4
30
71

2
1
6
2
1
1
1
22
1
38
292

2
1
6
1
0
0
0
22
1
34
190

---204,077
90,357
114,871
170,048
--961,742
357,782

COVERAGE OF MIDWIFE PERSONNEL


Total reported
District
deliveries
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

30
31
32
33
34
35
36
37
38

Kab. Pacitan
Kab. Ponorogo
Kab. Trenggalek
Kab. Tulungagung
Kab. Blitar
Kab. Kediri
Kab. Malang
Kab. Lumajang
Kab. Jember
Kab. Banyuwangi
Kab. Bondowoso
Kab. Situbondo
Kab. Probolinggo
Kab. Pasuruan
Kab. Sidoarjo
Kab. Mojokerto
Kab. Jombang
Kab. Nganjuk
Kab. Madiun
Kab. Magetan
Kab. Ngawi
Kab. Bojonegoro
Kab. Tuban
Kab. Lamongan
Kab. Gresik
Kab. Bangkalan
Kab. Sampang
Kab. Pamekasan
Kab. Sumenep

7,666
12,538
9,914
15,019
16,165
26,573
44,286
17,605
41,985
26,210
11,150
10,381
20,357
29,512
32,409
18,263
21,798
17,185
9,093
7,950
12,625
20,387
19,316
20,547
22,059
18,141
17,929
14,112
14,444

Sub-total Kabupaten

605,130

Kota. Kediri
Kota. Blitar
Kota. Malang
Kota. Probolinggo
Kota. Pasuruan
Kota. Mojokerto
Kota. Madiun
Kota. Surabaya
Kota. Batu
Sub-total Kota
TOTAL

3,486
1,870
15,178
3,927
3,781
1,880
2,524
49,459
3,330
93,047
49,678

Provincial Reproductive Health & MPS Profile of Indonesia

Total APN midwives

Total LSS midwives

37
68
157
5
8
6
20
60
50
0
87
0
40
53
176
30
342
181
56
2
142
113
183
322
143
18
154
135
86
2674
(1/ 226 deliveries)

5
0
40
33
2
0
13
0
0
0
19
0
15
0
0
10
15
181
0
0
142
51
72
24
0
0
45
25
10
702
(1 / 862 deliveries)

0
0
0
0
0
0
0
0
14
14
2688

0
0
0
0
0
0
0
0
0
0
702

BANTEN

he total population of Banten is 9.2 million,


accounting for 4% of the total population in
Indonesia, and 7% of the population in Java.
Banten is divided into 6 districts (4 kabupaten + 2 kota [cities]) with a total of 1483 villages. The
capital city is Serang.

GEOGRAPHY

Total land area (km2)


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

9019
6
4
2
135
1483

Beberapa Indikator Penting Sosial-EkonoBanten has a much higher urban population (60%) Source:
mi Indonesia, Edisi Juli 2006, BPS.
and much lower poor population (8%), compared to
the national average. Adult female literacy is slightly higher than the national rate at 91%.

The total fertility rate (2.6), crude birth rate (22.6) and modern contraceptive prevalence rate
(57%) are similar to the national averages. Among all contraceptive users, most women choose
injection (59%) or oral contraceptives (19%).
SOCIAL DEMOGRAPHY

Total population (2005)


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
1

Life expectancy at birth (2002) 2


Annual growth rate (2000-2005)
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6
2

Banten

9,155,208
60
8
91
1076
Male: 61
Female: 64
2.83
2,145,980 3
2.6
22.6
9.2
57.3
9.7

National

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000; CBR from West Java, which included Banten districts in 2000.
6
IDHS 2002/3
1
2

Health Facilities
Banten reports 21 hospitals; 6 public and 15 private.
There seems to be good coverage of specialists in
hospitals, though several districts did not report this
indicator.
All public hospitals (only 6) are certified as providers
of Comprehensive Emergency Obstetric and Neonatal
Care (CEONC) with one per district. Some private hospitals may provide CEONC service, but there
are no data reported from private hospitals on this indicator.

2005
Indonesia minimum
Coverage
standard
Public
Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)


Hospitals with CEONC

In-hospital OBGYN
In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in
Puskesmas
Puskesmas with bed

15 2

Not reported

Not reported

24 3

--

14

35 3

--

1 CEONC hospital / district


(WHO minimum standard:
one / 500,000 pop.)

Not calculated due to


under-reporting
Not calculated due to
under-reporting

One PHC / 30,000 pop.

1 / 52,315 pop.

159

--

1/ 57,580 pop.

25 4

--

14% of all puskesmas


9% of puskesmas
Average 2-3 / district;
0 / 4 districts have
none, (2 districts did
not report).
1 / 610,347 pop.

15 5

(WHO minimum standard:


One / 125,000 pop.)

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.


Kota Tanggerang did not report this indicator
3
Three of 6 districts (Serang, Lebak, Kota Tanggerang) did not report this indicator.
4
Three of 6 districts (Lebak, Kotal Cilegon, Kota Tanggerang) did not report this indicator.
5
Two of 6 districts (Kotal Cilegon, Kota Tanggerang) did not report this indicator.

1 / district
<1 / 500,000 pop.

175

4 / district
Puskesmas BEONC

--

Provincial Reproductive Health & MPS Profile of Indonesia

119

BANTEN
Banten has 175 puskesmas (primary health centers) with nearly as many puskesmas-based general practitioners (159). Only 14% of puskesmas have beds for in-patient care, but only 3 of 6
districts reported this indicator so provincial coverage cannot be accurately evaluated.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 15 puskesmas (<9%) report having received training and certification in Basic Emergency
Obstetric and Neonatal Care (BEONC). Two districts did not report this indicator. The current
World Health Organization (WHO) recommended standard for BEONC facilities is 1 for every
125,000 people. Indonesia has adopted this indicator, but translated it to mean at least four
BEONC facilities for each district.
Among reporting districts, there are only 2-3 BEONC facilities per district and far greater population supported by each BEONC than recommended. For every district to have 4 BEONC (and
assuming non-reporting districts have zero), an additional 10 would be required. However, since
Banten is so heavily populated, the recommended number of BEONC facilities according to population size is 74, or 59 more than currently reported.
One immediate step would be to upgrade the staff and facilities of each puskesmas with a bed
to BEONC level. Later efforts could be continued to reach the WHO recommended number of
BEONC facilities in each district. The cost per puskesmas team (3 persons) to be trained in
BEONC is 9.3 million (3.1 per person).

Health Personnel
HEALTH PERSONNEL
2005
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives (One / 3000 pop.)

30
38 2

Not reported
815

Midwives living in the village (One / village)

285

Midwives with a kit


Midwives trained in APN
Midwives trained in LSS
Total traditional birth attendants (TBA)
Trained TBA
TBA with kit

842
186 3
197 4
3294
3294
700 5

427

One district (Kota Tanggerang) did not report this indicator.


Two districts (Lebak, Kota Tanggerang) did not report this indicator.
3
Two districts (Lebak, Kota Cilegon) did not report this indicator.
4
Three districts (Lebak, Kota Cilegon, Kota Tanggerang) did not report this indicator.
5
One district (Kab. Tanggerang) did not report this indicator.
1
2

120

1 / 21,441 population
1 / 11,233 population
19% of villages have village
midwife
1 / 10,873 population
23% of midwives
1 / 46,473 population
100% of all TBA
21% of all TBA

On average, there is one Ob/Gyn specialist for every 300,000 population, and one pediatrician
for every 240,000 population. The total number of general practitioners meets the recommended
standard, but population coverage of midwives is below standard. An additional 2200 midwives
would be required to meet the standard of 1/3000 population. Only 1 in 5 (19%) of all villages
report having a midwife living in the village. Fewer than one-quarter (23%) of all midwives have
received APN training, with a similar proportion reporting BEONC training.
The data on reported health personnel is blank for West Java districts now part of Banten in 2001,
and Bantens reports from 2002-4 were mostly blank, making it difficult to identify improving or
deteriorating trends in coverage over time.

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in Banten of 22.6 (BPS, 2000), the reported pregnancies are nearly 13%
higher than the estimated pregnancies, and reported deliveries are 14% higher than estimated
deliveries. However, the proportion of deliveries to pregnancies, and newborn to deliveries is
valid and consistent with the country overall, suggesting that the reported events are reasonably
accurate. Likely explanations for this higher number of actual pregnancies, deliveries and newborn events compared to expected number may be that the crude birth rate in Banten is higher
than estimated or the population is higher than reported.
DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported / estimated 1

Reported pregnancies

258,694

2.83% of total population

112.6

Reported deliveries

247,676

95.7% of reported pregnancies

114.0

Reported newborn

235,524

95.1% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Antenatal Care Coverage


Among reported pregnancies, 90% of the women attended at least one antenatal visit (ANC1).
This drops to 72% coverage of 4 total antenatal visits (ANC4), which is below the 2007 target of
84%. Although ANC1 coverage may be relatively good, the difference between ANC4 and ANC1
shows that nearly 46,000 women who have accessed antenatal care once do not obtain the minimum standard of 4 antenatal visits. These women are either not adhering to the recommended
antenatal schedule or are accessing ANC too late to reach 4 visits. Quality of care, community awareness, and logistical accessibility factors likely account for these missed opportunities.

Provincial Reproductive Health & MPS Profile of Indonesia

BANTEN
Over 26,000 pregnant women never accessed any antenatal care.
The Indonesian Demographic Health Survey
(IDHS, 2002/3) describes the components of antenatal care provided in Banten. More than 95%
of women report having an abdominal examination and more than 83% report having their weight
and blood pressure measured. Just under 60%
received iron tablets. However, only 26% report
being informed of signs of pregnancy complications and only 27% gave a blood sample.
There is minimal variation in reported antenatal coverage by most districts, however, one district,
Kab Serang, reported low rates of ANC4 (52%) compared to the provincial average.

Skilled Birth Attendance


Nearly 2 out of 3 (63%) of all reported deliveries are attended by a skilled health professional
(SBA=skilled birth attendant). This leaves about
93,000 women delivering without any skilled birth
attendant. The national target for skilled birth attendance is 82% by 2007 and 90% by 2010.

Postnatal (Neonatal) Care Coverage


The IDHS estimates that fewer than 52% of all births are officially registered in Banten, similar to
the national estimated level (54%). Over 84% of all reported newborn attend the first neonatal
visit (KN1), and nearly all of those women also attend the second (KN2, 80%). The IDHS found
lower rates of early postnatal/neonatal care, but similar rates of missing care altogether (16%).

Banten is similar to the national estimates of birth


attendance and place of delivery from the IDHS:
About 12% are attended by a doctor, 51%
by a midwife or nurse, and 36% by a TBA.
Over 42% deliver at a health facility (public or private), and 57% deliver at home.
Three districts, Kab Lebak (47%), Serang (48%), Pandegang (52%), report
lower skilled birth attendant coverage
rates compared to the other three provinces (65%, 69%, 85%).
Trends in coverage of antenatal care and
skilled birth attendance cannot be evaluated from 2001-3 due to lack of reported
data. A drop of SBA attendance from 71%
to 63% between 2004 and 2005 may be
due to data reporting errors, but should be
observed closely in 2006 onwards.

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate of pregnant
women detected as at risk by the community, including cadres, TBAs or other
lay persons (i.e. non-health professionals). Indonesia adopted that 20% of
all pregnant women will need medical
attention during pregnancy or delivery,
or about 33,000 pregnant women in
Banten annually (20% of all pregnant
women reported).

Provincial Reproductive Health & MPS Profile of Indonesia

121

BANTEN
Overall, only 26% of this total number of women were detected as being at risk by community
members and 33% were detected by a health provider (denominator adjusted, applicable to reporting districts only).
About 4% of all expected maternal complications (20% of pregnancies) were managed by the
health care system at primary or tertiary levels of care. The national target for obstetric complications management is 60% by 2007 and 80% by 2010. Banten is far below national expectations
on this indicator. Kab Serang did not report the above indicators at all.
Management of neonatal complications (estimated to be 25% of newborn born) appears to be
even lower. While the national target for 2007 is 60%, increasing to 80% in 2010, Banten reports
managing less than 1% of all expected neonatal complications. Three districts did not report this
indicator (Kab Serang, Kab Lebak, Kab Tanggerang).

Maternal and Neonatal Deaths


There were 157 maternal deaths reported in
Banten in 2005, nearly 4% of all reported maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 67 / 100,000 live
births. This is smaller than national estimates
(MMR=230, range 58 to 440, WHO/UNICEF/
UNFPA, 2000 or MMR=307, IDHS, 2002/3) and
suggests serious under-reporting, though the
MMR in Banten may indeed be lower than the
national average.

Causes of Maternal Deaths, 2005


other /
unknown
37%

infection
10%

bleeding
37%

eclampsia
16%

The predominant cause of maternal death in


Banten is bleeding, though eclampsia plays a
significant role. Key interventions to reduce risk
of hemorrhage should be emphasized (iron deficiency anemia control, trained midwives, appropriate use of oxytocics in active management of
3rd stage as per national policy, access to safe
blood transfusion/fluid replacement). Women with signs or symptoms of hypertensive disorders
of pregnancy should be treated properly and actively referred to specialist care at a hospital, since
early delivery by c-section is the most effective measure to prevent progression to eclampsia and
death.
It should be noted that more than one-quarter (27%) of all maternal deaths are not attributed
to any immediate cause of death. More importance should be attached to correctly diagnosing
and recording causes of maternal deaths in order to more closely track progress toward effective management of obstetric complication and identify potential interventions to reduce maternal
mortality.

on reported data, Banten has a neonatal mortality rate of only 2.1 compared to a national estimate
of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the Banten data
on neonatal mortality are accurate enough to utilize as an outcome indicator. According to IDHS
2002/2003, the neonatal mortality rate is 16/1000 birhts. This province need some effort to achive
the 2009 target, 15/1000 briths.
The ratio of early to late neonatal deaths is not entirely consistent with international estimates
at 60%, suggesting that early neonatal deaths may be under-reported or misclassified. About
three-quarters of all neonatal deaths in Indonesia occur in the first 7 days of life suggesting the
importance of improving quality and access to pregnancy care, safer delivery and emergency
neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis,
and management of low birth weight newborn).
The reported stillbirth rate is 1.6 / 1000 estimated deliveries in Banten compared to the national
estimate of 17.

Hospital Management of Maternal and Neonatal Complications


Reported data from hospitals in Banten indicate that about 3% of all deliveries occur in hospital.
Over half of these deliveries (58%) are classified as complicated.
The case fatality rate for complications among hospital deliveries is moderate at 1.3% (WHO>1%)
and over 28% of all reported maternal deaths occurred in the hospital.
Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
HOSPITAL CASES
OB/GYN cases treated at hospital (includes
normal deliveries)
Complicated OB/GYN cases treated at hospital 2
Case fatality rate 3
Hospital admissions due to abortion
Caesarean sections

% of Hos% Coverage
pital Cases (reported pregnancies) 1

7583

--

4380

57.8

55

1.26

1303
2941

17.2
38.8

3.0% of all pregnancies


--

28.1% of reported maternal


deaths (196 in 2004) occurred in hospital
-1.2% of all deliveries

Denominators from 2004 data were pregnancies: 251,813; deliveries: 242,468.


Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1
2

The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based

122

Number

Provincial Reproductive Health & MPS Profile of Indonesia

BANTEN
Over 17% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion practices in Banten. With high rate of complicated cases
handled in hospital, 39% of all deliveries in hospital
are by caesarean section. The c-section rate over
all deliveries in the province is 1% and suggests
that there are many women delivering outside of
hospitals who would have had better outcomes if
delivered by c-section. Internationally, from 5-15%
of women are expected to require delivery by c-section for optimal maternal/neonatal outcome.

Data quality and reporting


10. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
11. Given the predominance of private hospitals in Banten, investigate data quality and completeness at private versus public hospitals to identify gaps or weaknesses (i.e. no private
hospital reported CEONC certification, what proportion of obstetric cases are handled in
private vs. public ).
12. Review systems for documenting and counting total deliveries, and live births to ensure
these important denominators are counted accurately.

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need to investigate apparent deficiencies, reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training, particularly
in districts reporting none. Ensure that every puskesmas has at least one trained ANC
midwife.
4. Investigate the reason behind low ANC1 coverage. Why do so many women never access
antenatal care? Investigate the reasons behind the difference between ANC4 and ANC1
rates of attendance. Who are these women entering the system but not being retained?
Why do they drop out?
5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
6. Increase the proportion of newborn and postpartum mothers who receive postnatal/postpartum care.

13. Investigate reasons behind lack of data reporting in many years, and incomplete data in
other years. District level comparisons and trend analysis is difficult to conduct with 2001-5
reported data.
14. Investigate data quality of all health input data both facility and personnel. These data
are critical for evaluating distribution of resources, and where to invest in increasing health
infrastructure to ensure equal access within the province.
15. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.
BEONC UNMET NEED ACCORDING TO STANDARDS (NR=not reported)
Total UnWHO rec#
Unmet
Total popmet Need
Pop. / ommended
District
BEONC
need
ulation
(MOH:
BEONC coverage
in 2005
(WHO)
4 / district)
(1 / 125,000)
1
2
3
4
5
6

Kab. Serang
Kab. Pandegang
Kab Lebak
Kab. Tanggerang
Kota Cilegon
Kota Tanggerang
TOTAL

1,776,995
1,099,758
1,125,474
3,317,331
324,654
1,510,996
9,155,208

4
2
3
6
NR
NR
15

0
2
1
0
(4)
(4)
3 11

444,249
549,879
375,158
552,889
--610,347

14
9
9
27
3
12
74

10
7
6
21
(3)
(12)
44 - 59

7. Improve management of obstetric and neonatal complications.


8. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
9. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Provincial Reproductive Health & MPS Profile of Indonesia

123

BANTEN
COVERAGE OF MIDWIFE PERSONNEL
Total reported
District
deliveries
1
2
3
4
5
6

Total APN midwives

Total LSS midwives

Kab. Serang
Kab. Pandegang
Kab Lebak
Kab. Tanggerang
Kota Cilegon
Kota Tanggerang

48895
30793
30718

65
43
Not reported

22
3
Not reported

88718
9267

62
Not reported

172
Not reported

39285

TOTAL

247,676

16
186
(1 / 1332 deliveries)

Not reported
197
1 / 1257 deliveries)

KEY INDICATORS AND NATIONAL TARGETS

Banten
2001 1

National Target
2005 *

2007

2010

ANC1 (K1)

89

ANC4 (K4)

72

84

95

SBA deliveries

63

82

90

Postpartum / Neonatal visit (KN1)

84

83

90

Risk detection of pregnant women by community

26
4.4

60

80

0.9

60

80

Obstetric complications managed


Neonatal complications managed

Not reported

Caesarian section rate (% of hospital deliveries)

39 *

Caesarian section rate (% of reported deliveries)

1.2 *

Hospital OB/GYN cases as % of all pregnancies

2.9 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

67

Although Banten was not a province in 2001, the districts of West Java that formed Banten in 2002 did not submit data on
these health indicators from 2001-2003, so indicators could not be calculated for analysis of trends.
* c-sections and hospital cases from 2004 data.
1

124

Provincial Reproductive Health & MPS Profile of Indonesia

BALI

he total population of Bali is 3.4 million, accounting for only 1.5% of the total population in Indonesia, and 29% of the population in the region
(Bali, East and West Nusa Tenggara). Bali is
divided into 9 districts (8 kabupaten + 1 kota [cities]) with
a total of 701 villages. The capital is Denpasar.
Bali has a higher urban population (58%) and far lower
poor population (7%) compared to the national average.
Adult female literacy is lower than the national rate at 79%.
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

GEOGRAPHY

Total land area (km2)


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

5449
9
8
1
55
701

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

Bali

3,389,560
58
7
79
600
Male: 68
Female: 72
1.41
795,510 3
2.1
18.1
6.5
58.9
6.9

National

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total
population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

The total fertility rate (2.1) and crude birth rate (18.1) are lower than the national average. The
modern contraceptive prevalence rate is similar (58%) and the percentage of young women who
have begun childbearing is lower than the national average (6.5%). Among all contraceptive
users, most women choose IUD (43%) or injection (36%). Other methods include tubal ligation/
vasectomy (8%), oral contraceptives (6%), or traditional methods (4%). Condom use for contra-

ception is higher than other provinces at 3%, but


still very low given the international tourism there,
and relatively high risk for sexually transmitted diseases, including HIV.

Health Facilities
Bali reports 40 hospitals; 16 public and 24 private. There is good coverage of Ob/Gyn and pediatric specialists in hospitals.
There are 17 hospitals certified as providers of Comprehensive Emergency Obstetric and Neonatal Care (CEONC) with 1-2 per district.
2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

16

24

Hospitals with CEONC 1

17

Not reported

In-hospital OBGYN
In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in
Puskesmas
Puskesmas with bed

53
55

35
23

1 CEONC hospital / district

1-2 / district
2.5 / 500,000 pop.

(WHO minimum standard:


one / 500,000 pop.)
-1 / 778 pregnant women
-1 / 798 newborn

109

One PHC / 30,000 pop.

1 / 31,097 pop.

161

--

1/ 21,053 pop.

21

--

19% of all puskesmas


17% of all puskesmas

4 / district
Puskesmas BEONC

--

18

(WHO minimum standard:


One / 125,000 pop.)

Average 2/district; 1/9


districts have none
1 / 183,309 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.

Provincial Reproductive Health & MPS Profile of Indonesia

125

BALI
Bali has 109 puskesmas (primary health centers) with even more puskesmas-based general
practitioners (161). Nearly 1 in 5 puskesmas (19%) has a bed for in-patient care. The population
covered by each puskesmas, on average, is slightly above the recommended standard.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 18 puskesmas (17%) report having received training and certification in Basic Emergency
Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO) recommended standard for BEONC facilities is 1 for every 125,000 people. Indonesia has adopted this
indicator, but translated it to mean at least four BEONC facilities for each district.
There are about 2 BEONC facilities per district, on average, with a population of about 183,000
supported by each BEONC. For every district to have 4 BEONC, a total of 36 would be required.
However, according to the population size of Bali, the minimum total number of BEONC facilities
recommended is only 27.
One immediate step would be to upgrade the staff and facilities at puskesmas in districts currently
under-served by BEONC and CEONC facilities (Karangasem, Bulelang, Denpasar). The cost
per puskesmas team (3 persons) to be trained in BEONC is IDR 9.3 million (3.1 per person).

Population coverage of midwives is very close to the recommended standard with 1/3100. 72% of
all villages are reported to have a midwife living in the village, with a significant increases in village
midwife coverage since 2001. Only 1 in 7 has received APN training, and only 13% are reported
to have received BEONC training.

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in Bali of 18.1 (BPS, 2000), the reported pregnancies are less than 1%
higher than the estimated pregnancies, and reported deliveries are similarly precise (1.5% higher)
compared to estimated deliveries. The proportion of deliveries to pregnancies, and newborn to
deliveries is valid and consistent with the country overall, further supporting the accuracy of the
reported events.
DENOMINATORS FOR KEY
Number
INDICATORS
Reported pregnancies
Reported deliveries
Reported newborn

HEALTH PERSONNEL
2001
2005
% Change
Coverage
(minimum standard)
Rows bordered in red are below minimum standard

OB/GYNs
Pediatricians
Primary health center general
practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in LSS
Total TBA
Trained TBA
TBA with kit

40
36

85
71

112%
97%

260

285

10%

39

96

146%

871

1093

25%

244

505

106%

577
Not reported
Not reported
781
586
380

350
165
142
493
221
291

39%
-- 37%
62%
23%

100.6
101.5
--

Antenatal Care Coverage


1 / 11,893 population

1 / 3101 population
72% of villages have village midwife
1 / 9684 population
15% midwives
1 / 23,870 population
45% of all TBA
59% of all TBA

The total number of specialists in Bali has grown substantially since 2001 and is among the best
staffed provinces in the country with one Ob/Gyn for every 40,000 and one pediatrician for every
48,000 people. Coverage of GPs also meets the recommended standard.

126

2.02% of total population


95.5% of reported pregnancies
95.2% of reported deliveries

Ratio of reported
/ estimated 1

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude
birth rate may be higher than estimated, the population may be higher than reported, or there is some doublecounting of events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Health Personnel

68,472
65,403
62,280

About 87% of the women attended up to four antenatal visits (ANC4). ANC1 coverage rates in 4
districts were inconsistent with reported pregnancies in those districts, reporting either extremely
high coverage (>150-325%) or unrealistically low
coverage (37%). Therefore, accurate ANC1 only
coverage could not be calculated. Data reported
for ANC4 coverage appeared more accurate and
consistent with reported pregnancies.
The coverage rate of 87% exceeds the national target for 2007 of 84%. Further progress toward
2010 goals (95%) could be made by focusing specifically on women who come for ANC1 but do
not complete ANC4. These women are either not adhering to the recommended antenatal schedule or are accessing ANC too late to reach 4 visits. Quality of care, community awareness, and
logistical accessibility factors likely account for these missed opportunities.

Provincial Reproductive Health & MPS Profile of Indonesia

BALI
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in Bali. More than 95% of women report having an abdominal examination,
weight and blood pressure measured, and 89% received iron tablets. However, only 19% report
being informed of signs of pregnancy complications and only 23% gave a blood sample. Bali has
one of the largest discrepancies between these measures, showing very high adherence to some
components of antenatal care, but lower than average adherence to critical components such as
preparing the woman for recognizing signs of pregnancy complications or risk, or screening blood
for typing and anemia assessment.
There is minimal variation in reported antenatal coverage in Bali districts.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that only 53% of all births are officially registered in Bali, similar to the national average. About 94% of all reported newborn attend the first and second neonatal visits
(KN1, KN2) and only 1% attend KN1 only. The IDHS found lower rates of postpartum/neonatal
care attendance, and significantly higher rates of missing care altogether (23%).
Given Balis high rates of facility delivery, skilled birth attendance and reported KN1 attendance,
the low rate of birth registration is unexpected.

Skilled Birth Attendance

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring
progress toward making pregnancy safer
is the rate of pregnant women detected as
at risk by the community, including cadres,
TBAs or other lay persons (i.e. non-health
professionals). Indonesia adopted that
20% of all pregnant women will need medical attention during pregnancy or delivery,
or nearly 14,000 pregnant women in Bali
annually (20% of all pregnant women reported).

Nearly 9 out of 10 (89%) of all reported deliveries are attended by a skilled health professional (SBA=skilled birth attendant). This coverage
is high, and exceeds the recommended target
for 2007 (82%), nearly meeting the 2010 target (90%). Fewer than 6900 women delivered
without a skilled attendant in Bali in 2005.
IDHS data on delivery attendance and place
of delivery are also good. More than onequarter (27%) are attended by a doctor, 61%
by a nurse or midwife, and fewer than 10% by
a TBA. Similarly, nearly 85% are estimated
to deliver in a health facility, and fewer than
14% deliver at home.

Overall, fewer than 4% of this total number


of women were detected as being at risk by community members and 62% were detected by a
health provider (denominator adjusted, applicable to reporting districts only).

Again, there is minimal variation in reported


SBA coverage by district. The trend in antenatal care coverage shows little change in these
indicators since 2001. There is an unexpected trend toward slightly declining SBA coverage since
2001.

Only 11% of all expected complications (20% of pregnancies) were managed by the health care
system at primary or tertiary levels of care. The national target for obstetric complications management is 60% by 2007 and 80% by 2010. Bali is far below national expectations on this indicator.
Management of neonatal complications (estimated to be 25% of newborn) appears to be even
lower. While the national target for 2007 is 60%, increasing to 80% in 2010, Bali reports managing less than 1% of all expected neonatal complications.

Provincial Reproductive Health & MPS Profile of Indonesia

127

BALI
Maternal and Neonatal Deaths
There were 35 maternal deaths reported in
Bali in 2005, less than 1% of all reported
maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 56
/ 100,000 live births. This is smaller than
national estimates (MMR=230, range 58
to 440, WHO/UNICEF/UNFPA, 2000 or
MMR=307, IDHS, 2002/3) and suggests under-reporting, though the MMR in Bali may
indeed be lower than the national average.

Hospital Management of Maternal and Neonatal Complications


Causes of Maternal Deaths, 2005
other /
unknown 37%
infection
14%

bleeding
29%

eclampsia
20%

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)

The predominant cause of maternal death


100
91
90
in Bali is bleeding, though eclampsia plays a
90
80
69
significant role. Key interventions to reduce
62
70
56
60
risk of hemorrhage should be emphasized
50
40
(iron deficiency anemia control, trained mid30
20
wives, appropriate use of oxytocics in active
10
0
management of 3rd stage as per national
2001
2002
2003
2004
2005
policy, access to safe blood transfusion/fluid
replacement). Women with signs or symptoms of hypertensive disorders of pregnancy
should be treated properly and actively referred to specialist care at a hospital, since early delivery by c-section is the most effective measure to prevent progression to eclampsia and death.
It should be noted that more than one-third (37%) of all maternal deaths are not attributed to
any immediate cause of death. More importance should be attached to correctly diagnosing
and recording causes of maternal deaths in order to more closely track progress toward effective management of obstetric complication and identify potential interventions to reduce maternal
mortality.
The number of reported stillbirths and neonatal deaths indicate serious under-reporting. Based
on reported data, Bali has a neonatal mortality rate of only 4.6 compared to a national estimate
of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the Bali data
on neonatal mortality are accurate enough to utilize as an outcome indicator. According to IDHS
2002/2003, the neonatal mortality rate is 9/1000 birhts. This province already over the 2009 target, 15/1000 briths.
The ratio of early to late neonatal deaths is consistent with estimates for Indonesia. More than
87% of all neonatal deaths in Bali occurred in the first 7 days of life suggesting the importance
of improving quality and access to pregnancy care, safer delivery and emergency neonatal care
(e.g. resuscitation, infection prevention, early detection and treatment of sepsis, and management of low birth weight newborn).
The reported stillbirth rate is 5.1 / 1000 estimated deliveries in Bali compared to the national
estimate of 17.

128

Reported data from hospitals in Bali indicate that over 12% of all deliveries occur in hospital.
Nearly one-half of these deliveries are classified as complicated.
The case fatality rate for complications among hospital deliveries is low at 0.4% and over 25% of
all reported maternal deaths occurred in the hospital.
Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
HOSPITAL CASES
OB/GYN cases treated at hospital
(includes normal deliveries)
Complicated OB/GYN cases
treated at hospital 2
Case fatality rate 3
Hospital admissions due to abortion
Caesarean sections

Number % of Hospital Cases

% Coverage
(reported pregnancies) 1

8279

--

12.3% of all pregnancies

3879

46.8

--

14

0.36

25.4% of reported maternal


deaths (55in 2004) occurred
in hospital

1951

23.6

--

3873

46.8

6.0% of all deliveries

Denominators from 2004 data were pregnancies: 67,445; deliveries: 64,426.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Nearly 24% of all hospital admissions are


due to abortion, suggesting a high rate of
unsafe abortion practices in Bali. More
than 46% of all deliveries in hospital are by
caesarean section. The c-section rate over
all deliveries in the province is high at 6.0%
(2nd to Jakarta only) and suggests that, on a
population level, most women who truly require c-section delivery are able to access
it. Internationally, from 5-15% of women are
expected to require delivery by c-section for
optimal maternal/neonatal outcome. However, given this high rate of c-sections in hospital and overall, it is also possible that a proportion of
them were medically unnecessary and some women still delivering at home or in poorly equipped
facilities are not accessing appropriate surgical delivery when needed.

Provincial Reproductive Health & MPS Profile of Indonesia

BALI
Recommendations

BEONC UNMET NEED ACCORDING TO STANDARDS

Coverage of health personnel and service inputs


1. Increase the number of BEONC facilities over the province. Ensure minimum standards of
distribution of BEONC facilities across all districts, and correlation with population size.
2. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife. With currently high rates of
SBA coverage, the most important agenda for Bali should be to aggressively upgrade the
technical skills of those attendants and ensure adequate access to well-prepared facilities.
3. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
4. Improve management of obstetric and neonatal complications. Again, given high rates of
SBA coverage, community awareness of pregnancy risk, and active commitment to ensuring good referral systems could contribute significantly toward even safer deliveries.
5. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
6. Investigate the possible reasons behind low birth registration rates and develop strategies
to encourage higher registration rates among the community, health providers, and bureaucrats.
7. Investigate the possible observed decline in SBA coverage over the past 5 years. Are
attitudes toward skilled birth attendants changing among community members, or is this
decline an artifact of reporting errors rather than a real situation?

District
1
2
3
4
5
6
7
8
9

Buleleng
Jembrana
Tabanan
Badung
Denpasar
Gianyar
Klungkung
Bangli
Karangasem
TOTAL

WHO recTotal
Total Unmet
Unmet
# BEONC
ommended
populaNeed (MOH: Pop. / BEONC
need
in 2005
coverage
tion
4 / district)
(WHO)
(1 / 125,000)
603,133
247,274
390,971
374,380
608,625
394,795
164,670
210,294
395,418
3,389,560

1
1
2
4
1
4
3
2
0
18

3
3
2
0
3
0
1
2
4
18

339,154
88,586
36,998
36,173
94,839
22,758
31,799
33,494
58,018
1 / 183,309 pop.

COVERAGE OF MIDWIFE PERSONNEL


Total reportDistrict
Total APN midwives
ed deliveries
1
2
3
4
5
6
7
8
9

Buleleng
Jembrana
Tabanan
Badung
Denpasar
Gianyar
Klungkung
Bangli
Karangasem

TOTAL

12,398
4,279
5,783
7,775
13,484
7,295
2,925
4,017
7,447
64,403

3
0
86
3
5
24
35
6
3
165
(1 / 390 deliveries)

5
2
3
3
5
3
1
2
3
27

4
1
1
0
4
0
0
0
3
13

Total LSS midwives


80
0
2
48
0
9
3
0
0
142
(1 / 453 deliveries)

8. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


9. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
10. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.
11. Given the predominance of private hospitals in Bali, investigate data quality and completeness at private versus public hospitals to identify gaps or weaknesses (i.e. no private hospital reported CEONC certification, what proportion of obstetric cases are handled in private
vs. public ).

Provincial Reproductive Health & MPS Profile of Indonesia

129

BALI
KEY INDICATORS AND NATIONAL TARGETS

Bali
2001

National Target

2005 *

2007

2010

ANC1 (K1)

97 1

Not valid

ANC4 (K4)

89

87

84

95

SBA deliveries

94 3

89

82

90

Postpartum / Neonatal visit (KN1)

96 4

95

83

90

Risk detection of pregnant women by community

1.8

3.8

Obstetric complications managed

Not reported

10.5

60

80

Neonatal complications managed

Not reported

0.8

60

80

Caesarian section rate (% of hospital deliveries)

35

47 *

Caesarian section rate (% of reported deliveries)

12.0

6.0 *

Hospital OB/GYN cases as % of all pregnancies

32.8

12.3 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

91

56

Three of 9 districts reported from 100-107% coverage, so this estimate could be higher than actual.
One of 9 districts reported > 100% coverage, so this estimate could be higher than actual.
3
Two of 9 districts reported f> 100% coverage, so this estimate could be higher than actual.
4
Two of 9 districts were not included due to over-reporting (Jembrana 192%; Kodya DPS 115%). One district (Badung) at
107% coverage was retained, so this estimate still could be higher than actual.
* c-section and hospital case data from 2004.
1
2

130

Provincial Reproductive Health & MPS Profile of Indonesia

WEST
KALIMANTAN

he total population of West Kalimantan


is 4.2 million, accounting for nearly 2%
of the total population in Indonesia, and
35% of the population in Kalimantan.
West Kalimantan is divided into 12 districts (10
kabupaten + 2 Kota [cities]) with a total of 1531
villages. The capital is Pontianak.
West Kalimantan has a far lower urban population (28%) and lower poor population (13%)
compared to the national average. Adult female
literacy is lower than the national rate at 83%.
SOCIAL DEMOGRAPHY

GEOGRAPHY
Total land area (km2)

120,114

Number of districts

12

Kabupaten (regencies)

10

Kota (municipalities)

Kecamatan (sub-districts)

154

Nagari/Kelurahan (villages)

1531

Source: Beberapa Indikator Penting Sosial-Ekonomi


Indonesia, Edisi Juli 2006, BPS.

West Kalimantan

National

4,176,554

220,659,431

28

48

13

17

83

87

30

116

Life expectancy at birth (2002) 2

Male: 62
Female: 66

Male: 64
Female: 68

Annual growth rate (2000-2005) 2

1.82

1.34

Total population (2005)

Percent urban population (2005)


Percent poor population (2004)

Adult female literacy rate (2004)

Population density (km sq.; 2005) 2

Women of reproductive age

978,980

51,732,453 4

Total fertility rate / 1000 women 6

2.9

2.6

Crude birth rate / 1000 pop. (2000) 5

23.6

22.0

Percentage of women 15-19 who have begun childbearing 6

9.3

10.4

Modern contraceptive prevalence (%) 6

55.7

56.7

Unmet need for contraception (%) 6

10.1

8.6

From provincial health data reports.


2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total
population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3

The total fertility rate (2.9) and crude birth rate (23.6)
are similar to the national average. The modern contraceptive prevalence rate is also similar (56%) as
is the percentage of young women who have begun
childbearing (9.3%). Among all contraceptive users,
most women choose injection (53%) or oral contraceptives (27%) or implants (9%).

Contraceptive Methods Used


(IDHS 2002/3)
injection,
53%

pill, 27%

im plant, 9%
traditional
m ethods,
4%

condom ,
1%

perm anent
, 2%

IUD, 4%

Health Facilities
All indicators for West Kalimantan are significantly under-reported because from 2 to 11 districts
(out of 12 total) did not report some indicators. Therefore, accurate coverage rates of many indicators cannot be calculated.
West Kalimantan reports 16 hospitals, half of them private. Only 6 of the 8 reported public hospitals are certified as providers of Comprehensive Emergency Obstetric and Neonatal Care
(CEONC) with at least one per reporting district (Kab Landak, Kab Sanggau, Kab Sekadau,
Kab Sintang, and Kab Ketapang did not report).
West Kalimantan has 176 puskesmas (primary health centers) in 10 out of 12 districts, with fewer
puskesmas-based general practitioners (144). One-third (33%) of puskesmas have beds for inpatient care. Coverage of puskesmas meets the recommended standard.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 14 puskesmas (8%) report having received training and certification in Basic Emergency
Obstetric and Neonatal Care (BEONC), but 5 out of 12 districts did not report this indicator. The
current World Health Organization (WHO) recommended standard for BEONC facilities is 1 for
every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least
four BEONC facilities for each district.

Among reporting districts, there are about two BEONC facilities per district. But overall, more
than twice the population is supported by each BEONC than recommended. For every district
to have 4 BEONC, up to 34 would be required (assuming non-reporting districts currently have
none). However, given the population size of West Kalimantan, the total recommended number

Provincial Reproductive Health & MPS Profile of Indonesia

131

WEST KALIMANTAN
HEALTH FACILITIES

2005
Public Private

Indonesia minimum standard

Coverage

Rows bordered in red are below minimum standard


Total hospitals (general)

81

82

-1 CEONC hospital /
district

Hospitals with CEONC 8

63

NR

In-hospital OBGYN

In-hospital pediatricians

(WHO minimum
standard:
one / 500,000 pop.)

--

--

< 1 / district
<1 / 500,000 pop.

Not calculated due to underreporting

176 6

One PHC / 30,000


pop.

1 / 23,730 population 6

General practitioner in
Puskesmas

144 6

--

1/ 29,004 population 6

Puskesmas with bed

57 6

--

32% of all puskesmas

Puskesmas BEONC

14

(WHO minimum
standard:
One / 125,000 pop.)

a. Kota Pontianak
e. Kab. Bengkayang
b. Kab. Pontianak
f. Kab. Landak
c. Kota Singkawang
g. Kab. Sanggau
d. Kab. Sambas
h. Kab. Sekadau
1
Districts reporting 8/12 (missing districts # e, h, j, k)
2
Districts reporting 4/12 (missing districts # b, d, e, f, h, i, j, k)
3
Districts reporting 6/12 (missing districts #e, f, h, i, j, k)
4
Districts reporting 2/12 (missing districts #b, c, d, e, g, h, i, j, k, l)
5
Districts reporting 1/12 (missing districts # b, c, d, e, f, g, h, i, j, k, l)
6
Districts reporting 10/12 (missing districts # g, h).
7
Districts reporting 7/12 (missing districts #f, g, h, i, l).
8
Comprehensive Emergency Obtsetric and Neonatal Care, 24 hour service.

8% of all puskesmas
Average 2/ district among 7
reporting districts

2001

2005

% Change

Coverage

OB/GYNs

Not reported

15 1

--

Pediatricians

Not reported

11

--

Primary health center general


practitioners
(One GP / 30,000 pop.)

143 3

138 4

4%

Nurses trained in ANC

167 3

-- 5

--

Total midwives
(One / 3000 pop.)

1500 3

1165 6

22%

1 / 3585 population 14

Midwives living in the village


(One / village)

943 7

788 8

16%

51% of villages have


village midwife

Midwives with a kit

1115 7

1064

5%

1 / 3925 population

--

15% of midwives

--

--

1 / 30,265 population

1 / 298,325 pop.

Midwives trained in APN

Not reported

177

i. Kab. Sintang
j. Kab. Melawi
k. Kab. Kapuas Hulu
l. Kab. Ketapang

Midwives trained in LSS

Not reported

-- 10

Total TBA

4888 3

2578 11

Not calculated

Trained TBA

3744

1017

Not calculated

39% of all TBA

TBA with kit

3358

622

Not calculated

24% of all TBA

of BEONC facilities is 35. Taking into account variation in coverage by population density, a total
of 7-22 more BEONC facilities are recommended.
One immediate step would be first to compile accurate and current data on the distribution of
CEONC and BEONC facilities in West Kalimantan. Then to identify which puskesmas already
having beds could be upgraded to the BEONC level, focusing first on districts currently underserved by BEONC and CEONC facilities. The cost per puskesmas team (3 persons) to be trained
in BEONC is 9.3 million (3.1 per person).

12

13

a. Kota Pontianak
e. Kab. Bengkayang
i. Kab. Sintang
b. Kab. Pontianak
f. Kab. Landak
j. Kab. Melawi
c. Kota Singkawang
g. Kab. Sanggau
k. Kab. Kapuas Hulu
d. Kab. Sambas
h. Kab. Sekadau
l. Kab. Ketapang
1
Districts reporting 8/12 (missing districts # e, h, j, k)
2
Districts reporting 6/12 (missing districts # e, f, h, j, k)
3
Districts reporting 8/9 (missing districts # f)
4
Districts reporting 9/12 (missing districts #g, h, i)
5
Districts reporting only 3/12 (missing districts #a, b, c, d, g, h, j, k,l)
6
Districts reporting 10/12 (missing districts # g, h)
7
Districts reporting 8/9 (missing districts # a)
8
Districts reporting 11/12 (missing districts # a)
9
Districts reporting 11/12 (missing districts #h)
10
Districts reporting 3/12 (missing districts #a, b, c, d, f, h, i, k, k); provincial total not reported above.
11
Districts reporting 8/12 (missing districts #3, 7, 8, 11)
12
Districts reporting 6/12 (missing districts #3, 4, 5, 7, 8, 11)
13
Districts reporting 6/12 (missing districts #2, 3, 4, 7, 8, 11)
14
Population coverage denominator adjusted for non-reporting districts.

Primary Health Care Indicators

Health Personnel
The coverage of specialists in West Kalimantan, though not reported in several districts, appears

132

HEALTH PERSONNEL
(minimum standard)

Rows bordered in red are below minimum standard

Puskesmas
(primary health centers)

4 / district

to be inadequate with only one Ob/Gyn for every 280,000 and one pediatrician for every 380,000
people. Coverage of GPs just meets the recommended standard. Population coverage of midwives is a little below the standard, but may have met the standard if all districts had reported
data. About 50% of all villages are reported to have a midwife living in the village, and this coverage has decreased slightly since 2001. Only 15% of midwives have received APN training, and
the proportion with BEONC training was not calculated because only 3 districts reported that
indicator.

The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.

Provincial Reproductive Health & MPS Profile of Indonesia

WEST KALIMANTAN
Assuming a crude birth rate in West Kalimantan of 23.6 (BPS, 2000), the reported pregnancies
are slightly lower (1.5%) than the estimated pregnancies, and reported deliveries are similarly
lower (1%) than estimated deliveries. The proportion of deliveries to pregnancies, and newborn
to deliveries is valid and consistent with the country overall, suggesting that the reported events
are reasonably accurate. Likely explanations for this slightly lower number of reported pregnancies and deliveries compared to the expected number may be that the crude birth rate in West
Kalimantan is lower than estimated or the population is lower than reported.

Skilled Birth Attendance


Place of Delivery (IDHS, 2002/3)

Skilled Birth Attendant Coverage


2005
no SBA
34%

80.0%
60.0%
40.0%

SBA
66%

20.0%
0.0%

DENOMINATORS FOR KEY


Number
INDICATORS

Ratio of reported /
estimated 1

Reported pregnancies

107,762

2.58% of total population\

98.5

Reported deliveries

102,281

94.9% of reported pregnancies

98.8

Reported newborn

97,211

95.0% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Antenatal Coverage
Among reported pregnancies, 86% of the
Antenatal Care Coverage 2005
women attended at least one antenatal visit
(ANC1). This drops to 76% coverage of 4
ANC1 & 4
total antenatal visits (ANC4), which is below
76%
the 2007 target of 84%. Although ANC1 covANC1 only
no ANC
10%
erage is moderate, the difference between
14%
ANC4 and ANC1 shows that over 10,000
women who have accessed antenatal care
once do not obtain the minimum standard of
4 antenatal visits. These women are either not adhering to the recommended antenatal schedule
or are accessing ANC too late to reach 4 visits. Quality of care, community awareness, and logistical accessibility factors likely account for these missed opportunities. Nearly 15,000 pregnant
women never accessed any antenatal care in West Kalimantan.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in West Kalimantan. More than 90% of women report having an abdominal
examination; more than 84% report having their weight and blood pressure measured. However,
only 66% received iron tablets, 36% report being informed of signs of pregnancy complications
and only 44% gave a blood sample. These data show that critical components of antenatal
care are often not provided, and the overall quality of antenatal care should be examined more
closely.
There is minimal variation in reported antenatal coverage by most districts.

Only two-thirds (66%) of all reported deliveries are attended by a skilled health
professional (SBA=skilled birth attendant).
This leaves more than 34,000 women delivering without any skilled birth attendant.
The national target for skilled birth attendance is 82% by 2007 and 90% by 2010;
West Kalimantan is far behind this expectation.

public health private health


facility
facility

home

other /
missing

West Kalimantan

7.4%

17.6%

72.8%

2.2%

Indonesia

9.2%

30.5%

59.0%

1.2%

Assistance During Delivery (IDHS, 2002/3)


60.0%
40.0%
20.0%
0.0%

Ob/Gyn or
GP

midw ife or
nurse

TBA

relative or
other

nobody

West Kalimantan

6.7%

57.0%

33.3%

1.8%

0.0%

Indonesia

11.0%

55.3%

31.5%

1.3%

1.1%

West Kalimantan closely mirrors the national average of birth attendance and place of
delivery estimates from the IDHS: About
7% are attended by a doctor, 57% by a
midwife or nurse, and 35% by a TBA, relative or other person. Only 25% deliver at
a health facility (public or private), with the
majority (73%) delivering at home.

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005
100.0%
50.0%
0.0%
k4

2001

2002

2003

2004

2005

77.4% 81.6% 77.6% 79.9% 76.3%

SBA 64.7% 68.7% 65.4% 68.9% 66.5%

Again, there is minimal variation in reported SBA coverage by most districts, however, three districts, Kab Sanggau, Kab Sekadau, and Kab Melawi, report low rates of SBA coverage (53%,
52% and 49% respectively).
There is no trend or change in antenatal care and SBA coverage between 2001 and 2005.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that only 40% of all births are
officially registered in West Kalimantan, much lower
than the national average. About 53% of all reported
newborn attend the first and second neonatal visits
(KN1, KN2) and 5% attend KN1 only. Thus, health
data suggest that 43% of women/neonates do not
receive postpartum/neonatal care. These data are
not consistent with the IDHS which found higher

Provincial Reproductive Health & MPS Profile of Indonesia

Postpartum / Neonatal Care


Coverage 2005
KN1 only,
5%
KN1 &
KN2, 53%

no
postnatal /
neonatal
care, 43%

133

WEST KALIMANTAN
rates of postpartum/neonatal care attendance, and much lower rates of missing care altogether
(17%).

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy
safer is the rate of pregnant women
detected as at risk by the community,
including cadres, TBAs or other lay persons (i.e. non-health professionals). Indonesia adopted that 20% of all pregnant
women will need medical attention during
pregnancy or delivery, or nearly 11,000
pregnant women in West Kalimantan
annually (20% of all pregnant women reported).
Overall, only 14% of this total number of
women was detected as being at risk by
community members and 48% were detected by a health provider.

Causes of Maternal Deaths, 2005


bleeding
43%

other /
unknown
49%

eclampsia
7%
infection

Birth Registration and Postnatal Care (IDHS, 2002/3)


80.0%
60.0%
40.0%
20.0%
0.0%

birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

West Kalimantan

40.3%

54.0%

21.7%

7.4%

16.5%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

Pregnancy Risk Detection


and Management of Complications
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%

detected by
community

detected by health
provider

maternal
complications
managed

About 24% of all expected maternal com14.4%


48.1%
23.8%
denominator=20% reported
pregnancies
plications (20% of pregnancies) were
2.9%
9.6%
4.8%
denominator=all pregnant
w omen
managed by the health care system at
primary or tertiary levels of care. The national target for obstetric complications management is 60% by 2007 and 80% by 2010. West
Kalimantan is far below national expectations on this indicator.
Management of neonatal complications (estimated to be 25% of newborn) appears to be even
lower. While the national target for 2007 is 60%, increasing to 80% in 2010, West Kalimantan
reports managing 14% of all expected neonatal complications.

1%
It should be noted that nearly one-half (49%) of all
maternal deaths are not attributed to any
Maternal Mortality Ratio, 2001-05
immediate cause of death. More impor(deaths / 100,000 reported newborn)
tance should be attached to correctly diagnosing and recording causes of mater- 140
117
116
nal deaths in order to more closely track 120
100
progress toward effective management 100
69
80
of obstetric complication and identify po60
tential interventions to reduce maternal
40
20
mortality.

72

2001

2002

2003

2004

2005

The number of reported stillbirths and


neonatal deaths indicates serious underreporting. Based on reported data, West Kalimantan has a neonatal mortality rate of only 3.5
compared to a national estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore,
it is unlikely that the West Kalimantan data on neonatal mortality are accurate enough to utilize as
an outcome indicator. According to IDHS 2002/2003, the neonatal mortality rate is 24/1000 births.
This province need some effort to achive the 2009 target, 15/1000 births.
The ratio of early to late neonatal deaths is consistent with estimates for Indonesia. More than
64% of all neonatal deaths in West Kalimantan occurred in the first 7 days of life suggesting the
importance of improving quality and access to pregnancy care, safer delivery and emergency
neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis,
and management of low birth weight newborn).
The reported stillbirth rate is 4.0 / 1000 estimated deliveries in West Kalimantan compared to the
national estimate of 17.

Hospital Management of Maternal and Neonatal Complications

Maternal and Neonatal Deaths


There were 70 maternal deaths reported in West Kalimantan in 2005, nearly 2% of all reported
maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 72 / 100,000 live
births. This is far smaller than national estimates (MMR=230, range 58 to 440, WHO/UNICEF/
UNFPA, 2000 or MMR=307, IDHS, 2002/3) and suggests under-reporting.
The predominant cause of maternal death in West Kalimantan is bleeding, though eclampsia plays
a significant role. Key interventions to reduce risk of hemorrhage should be emphasized (iron
deficiency anemia control, trained midwives, appropriate use of oxytocics in active management
of 3rd stage as per national policy, access to safe blood transfusion/fluid replacement). Women

134

with signs or symptoms of hypertensive disorders of


pregnancy should be treated properly and actively
referred to specialist care at a hospital, since early
delivery by c-section is the most effective measure
to prevent progression to eclampsia and death.

Reported data from hospitals in West Kalimantan indicate that less than 5% of all deliveries occur
in hospital. More than 40% of these deliveries are classified as complicated.
The case fatality rate for complications among hospital deliveries is low at 0.4%, but only 14% of
all reported maternal deaths occurred in the hospital.
Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in

Provincial Reproductive Health & MPS Profile of Indonesia

WEST KALIMANTAN
HOSPITAL CASES

% of HospiNumber
tal Cases

% Coverage
(reported pregnancies) 1

OB/GYN cases treated at hospital (includes normal deliveries)

5402

--

5.2% of all pregnancies

Complicated OB/GYN cases treated at


hospital 2

2195

40.6

--

0.41

13.8% of reported maternal


deaths (65 in 2004) occurred
in hospital

Hospital admissions due to abortion

708

13.1

--

Caesarean sections

1307

24.2

1.3% of all deliveries

Case fatality rate 3

Denominators from 2004 data were pregnancies: 103,992; deliveries: 98,475.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

the HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.

Obstetric Complications at Hospital 2004

abortion
32%

other /
unknown
38%

Nearly 13% of all hospital admissions are due to


bleeding
abortion, suggesting a high rate of unsafe abor9%
eclampsia
19%
infection
tion practices in West Kalimantan. About 24% of
2.5%
all deliveries in hospital are by caesarean section.
The c-section rate over all deliveries in the province is 1.3% and suggests that there are women delivering outside of hospitals who would have
had better outcomes if delivered by c-section. Internationally, from 5-15% of women are expected
to require delivery by c-section for optimal maternal/neonatal outcome.

drop out?
5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Investigate the possible reasons behind low birth registration rates and develop strategies
to encourage higher registration rates among the community, health providers, and bureaucrats.
8. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
9. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
10. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


11. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
12. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
13. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.
4. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they

Provincial Reproductive Health & MPS Profile of Indonesia

135

WEST KALIMANTAN
BEONC UNMET NEED ACCORDING TO STANDARDS (NR=not reported)
WHO recTotal
#
Total Unmet
Unmet
Pop. / ommended
District
popula- BEONC Need (MOH:
need
BEONC coverage
tion
in 2005 4 / district)
(WHO)
(1 / 125,000)

1
2
3
4
5
6
7
8
9
10
11
12

Kota Pontianak
Kab. Pontianak
Kota Singkawang
Kab. Sambas
Kab. Bengkayang
Kab. Landak
Kab. Sanggau
Kab. Sekadau
Kab. Sintang
Kab. Melawi
Kab. Kapuas Hulu
Kab. Ketapang
TOTAL

501,826
691,150
175,250
465,782
210,684
309,128
377,544
256,123
343,278
157,778
200,652
487,359
4,176,554

3
2
1
2
3
NR
NR
NR
NR
1
2
NR
14

COVERAGE OF MIDWIFE PERSONNEL


District
Total reported deliveries
1
Kota Pontianak
10,538
2
Kab. Pontianak
14,270
3
Kota Singkawang
4,600
4
Kab. Sambas
12,961
5
Kab. Bengkayang
5,719
6
Kab. Landak
8,212
7
Kab. Sanggau
10,192
8
Kab. Sekadau
4,643
9
Kab. Sintang
8,178
10 Kab. Melawi
3,866
11 Kab. Kapuas Hulu
6,309
12 Kab. Ketapang
12,793
TOTAL

136

102,281

1
2
3
2
1
(4)
(4)
(4)
(4)
3
2
(4)
14 - -34

167,275
345,575
175,250
232,891
70,228
----157,778
100,326
-298,325

Total APN midwives

4
12
32
15
29
14
12
Not reported
28
2
24
5
177
(1 / 578 deliveries)

4
6
1
4
2
3
3
2
3
1
2
4
35

1
4
0
2
0
(3)
(3)
(2)
(3)
0
0
(4)
7 - 22

KEY INDICATORS AND NATIONAL TARGETS

West Kalimantan
2001

2005*

ANC1 (K1)

81

86

ANC4 (K4)

77

Deliveries with skilled birth attendant

National Target
2007

2010

76

84

95

65

66

82

90

Neonatal visit (KN)

68

57

83

90

Risk detection of pregnant women by community

11

14.4

Obstetric complications managed

NR

23.8

60

80

Neonatal complications managed

NR

14.3

60

80

Caesarian section % of hospital deliveries*

17

24

Caesarian section % of all deliveries*

1.4

1.3

Hospital OB/GYN cases as % of all pregnancies*

7.9

5.2

Maternal Mortality Ratio

121

70

* c-section and hospital case data from 2004.

Total LSS midwives


Not reported
Not reported
Not reported
Not reported
68
Not reported
12
Not reported
Not reported
2
Not reported
Not reported
82
1 / 1247 deliveries)

Provincial Reproductive Health & MPS Profile of Indonesia

CENTRAL
KALIMANTAN

he total population of Central Kalimantan is 1.9 million, accounting for nearly


1% of the total population in Indonesia, and 15.5% of the population in
Kalimantan. Central Kalimantan is divided into
14 districts (13 kabupaten + 1 Kota [cities]) with
a total of 1395 villages. The capital is Palankaraya.

GEOGRAPHY
Total land area (km2)

153,565

Number of districts

14

Kabupaten (regencies)

13

Kota (municipalities)

Kecamatan (sub-districts)

105

Kelurahan/Desa (villages)

1395

Source: Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.

Central Kalimantan has a far lower urban population (34%) and lower poor population (9%)
compared to the national average. Adult female literacy is higher than the national rate at 95%.
The total fertility rate (3.2) and crude birth rate (24.7) are higher than the national average. Although modern contraceptive prevalence rate is higher (63%), the percentage of young women
who have begun childbearing is also higher (18.6%). Among all contraceptive users, most women
choose oral contraceptives (52%) or injection (41%).
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

Central Kalimantan
1,867,323
34
9
95
14
Male: 67
Female: 71
2.87
437,680 3
3.2
24.7
18.6
62.9
6.8

National

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1
2

Health Facilities
Central Kalimantan reports 12 hospitals in 2004
(none were reported in 2005), all of them public.
Only 8 OB/Gyns and 8 pediatricians work in hospitals.

Contraceptive Methods Used


(IDHS 2002/3)

There are only 6 hospitals certified as providers of


traditional
Comprehensive Emergency Obstetric and Neona- methods, 1%
condom, 1%
tal Care (CEONC) with only eight districts reporting
none (Lamandau, Sukamara, Katingan, Seruyan,
Pulang Pisau, Gunung Mas, Barito Selatan, Barito Timur).
HEALTH FACILITIES

2005
Public Private

pill, 52%

injection,
41%

Indonesia minimum
standard

IUD, 1%
implant, 4%

permanent,
1%

Coverage

Rows bordered in red are below minimum standard


Total hospitals (general)
12 2
0
-1 CEONC hospital / district
<1 / district
Hospitals with CEONC 1
6
NR
(WHO minimum standard: 1.6 / 500,000 pop.
one / 500,000 pop.)
1 / 6728 pregnant
In-hospital OBGYN
8
0
-women
In-hospital pediatricians
8
0
-1 / 5922 newborn
Puskesmas
142
One PHC / 30,000 pop.
1 / 13,150 pop.
(primary health centers)
General practitioner in
119
-1/ 15,691 pop.
Puskesmas
Puskesmas with bed
135
-95% of all puskesmas
4 / district
Not reported in
Puskesmas BEONC
-2004 and 2005
(WHO minimum standard:
One / 125,000 pop.)
1
2

Comprehensive Emergency Obsetric and Neonatal Care, 24 hour service.


None were reported in 2005; there were 12 reported in 2004.

Central Kalimantan has 142 puskesmas (primary health centers) with fewer puskesmas-based general practitioners (119). Almost all (95%) puskesmas are reported to have beds for in-patient care,
which is a very unusual report and should be verified.

Provincial Reproductive Health & MPS Profile of Indonesia

137

CENTRAL KALIMANTAN
Access to Basic Emergency Obstetric Care (BEONC or PONED)
The number of puskesmas having received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC) was not reported in 2004 and 2005. The current World Health
Organization (WHO) recommended standard for BEONC facilities is 1 for every 125,000 people.
Indonesia has adopted this indicator, but translated it to mean at least four BEONC facilities for
each district.
For every district to have 4 BEONC, Central Kalimantan should have 56 BEONC facilities. However, according to the population size of Central Kalimantan, the total recommended number of
BEONC facilities is only 18.
One immediate step would be to review the actual number of BEONC puskesmas in the province,
then identify districts with more than 125,000 population for each BEONC as priority districts for
additional training. The first goal should be to reach at least 18 well-distributed BEONC facilities, and then to increase that number toward 56, with special emphasis on areas with limited
access to CEONC centers. The cost per puskesmas team (3 persons) to be trained in BEONC
is 9.3 million (3.1 per person).

Health Personnel
HEALTH PERSONNEL
2001
2005 % Change
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general
practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in LSS
Total TBA
Trained TBA
TBA with kit

Not reported
Not reported

8
7

---

Not reported

167

--

Not reported

--

1004

1074

7%

736

683

7%

1004
Not reported
Not reported
Not reported
Not reported
Not reported

1074
40
0
3348
912
2446

7%
------

DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported
/ estimated 1

Reported pregnancies

53,827

2.88% of total population

105.1

Reported deliveries

50,102

93.1% of reported pregnancies

103.5

Reported newborn

47,373

94.6% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in Central Kalimantan of 24.7 (BPS, 2000), the reported pregnancies
are higher (5%) than the estimated pregnancies, and reported deliveries are similarly higher (4%)
than estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries
is valid and consistent with the country overall, suggesting that the reported events are reasonably accurate. Likely explanations for this higher number of reported pregnancies and deliveries
compared to the expected number may be that the crude birth rate in Central Kalimantan is higher
than estimated or the population is higher than reported.

Antenatal Care Coverage


1 / 11,181 population

1 / 1739 population
49% of villages have village
midwife
1 / 1739 population
4% of midwives
-27% of all TBA
73% of all TBA

The coverage of specialists in Central Kalimantan appears to be inadequate with only one Ob/
Gyn for 230,000 and one pediatrician for 267,000 people. Coverage of GPs meets the recommended standard. Population coverage of midwives also meets the standard. However, less
than half (49%) of all villages are reported to have a midwife living in the village, and this coverage
has only decreased slightly since 2001. Less than 4% of midwives have received APN training,
and the proportion with BEONC training was not reported.

138

Primary Health Care Indicators

Among reported pregnancies, 90% of the women


Antenatal Care Coverage 2005
attended at least one antenatal visit (ANC1). This
drops to 77% coverage of 4 total antenatal visits
ANC1 & 4
(ANC4), which is below the 2007 target of 84%. Al77%
though ANC1 coverage is relatively good, the differANC1 only
no ANC
13%
ence between ANC4 and ANC1 shows that nearly
10%
7000 women who have accessed antenatal care
once do not obtain the minimum standard of 4 antenatal visits. These women are either not adhering
to the recommended antenatal schedule or are accessing ANC too late to reach 4 visits. Quality
of care, community awareness, and logistical accessibility factors likely account for these missed
opportunities. Over 5000 pregnant women never accessed any antenatal care in Central Kalimantan.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in Central Kalimantan. Only 84% of women report having an abdominal examination; 76% report having their blood pressure measured and 68% report having their weight
measured. Only 58% received iron tablets, 51% report being informed of signs of pregnancy
complications and 16% gave a blood sample. These data show that critical components of an-

Provincial Reproductive Health & MPS Profile of Indonesia

CENTRAL KALIMANTAN
tenatal care are often not provided, and the overall quality of antenatal care should be examined
more closely. However, 51% being informed of signs of pregnancy complications, though still less
than ideal, is the highest rate among all provinces for this measure, much higher than the national
average of only 29%.
There is minimal variation in reported antenatal coverage by most districts, however, one district,
Katingan, reported low rates of ANC1 and ANC4 (64% for both) and another district (Barito Selatan) reported low rates for ANC4 (60%) compared to the provincial average.

There has been a slight trend toward increasing coverage of antenatal care by
about 5 percentage points, and a larger
increase in SBA coverage (about 7 percentage points) between 2001 and 2005.

Birth Registration and Postnatal Care (IDHS, 2002/3)


80.0%
60.0%

Three-quarters (75%) of all reported deliveries are attended by a skilled health professional
(SBA=skilled birth attendant). This leaves more
than 12,500 women delivering without any skilled
birth attendant. The national target for skilled birth
attendance is 82% by 2007 and 90% by 2010; Central Kalimantan is behind this expectation.

Again, there is minimal variation in reported SBA coverage by most districts, however, one district, Pulang Pisau, reported
low rates of SBA coverage (62%).

The IDHS estimates that only 36% of all births are officially registered in Central Kalimantan,
much lower than the national average. About 83% of all reported newborn attend the first and
second neonatal visits (KN1, KN2) and 1% attends KN1 only. These data are consistent with the
IDHS which found similar rates of postpartum/neonatal care attendance, and rates of missing
care altogether (18%).
Postpartum / Neonatal Care
Coverage 2005

Skilled Birth Attendance

Women in Central Kalimantan are far less


likely to deliver with a doctor or nurse/midwife compared to the Indonesian average.
Only 1% is attended by a doctor and 45%
by a midwife or nurse. More than half
(51%) are delivered by a TBA, relative or
other person. Similarly, only 3% deliver at
a health facility, with the majority (94%) delivering at home. Central Kalimantan has
the highest rate of home delivery among
all provinces in Indonesia. These data are
not consistent with SBA coverage as reported by the HIS.

Postpartum (Neonatal) Care Coverage

Skilled Birth Attendant Coverage


2005
no SBA
25%

60.0%
40.0%
20.0%
home

other /
missing

Central Kalimantan

1.4%

1.6%

94.2%

2.9%

Indonesia

9.2%

30.5%

59.0%

1.2%

Assistance During Delivery (IDHS, 2002/3)


60.0%
40.0%
20.0%
Ob/Gyn or midw ife or
GP
nurse

TBA

relative or
other

nobody

Central Kalimantan

1.3%

44.8%

48.8%

2.2%

0.0%

Indonesia

11.0%

55.3%

31.5%

1.3%

1.1%

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005
100.0%
50.0%
0.0%
k4

2001

2002

2003

2004

0.0%

KN1 only,
1%

In Indonesia one of the indicator measuring


progress toward making pregnancy safer
is the rate of pregnant women detected as
at risk by the community, including cadres, TBAs or other lay persons (i.e. nonhealth professionals). Indonesia adopted
that 20% of all pregnant women will need
medical attention during pregnancy or delivery, or nearly 11,000 pregnant women
in Central Kalimantan annually (20% of all
pregnant women reported).

80.0%

public health private health


facility
facility

20.0%
birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

Central Kalimantan

36.3%

78.3%

2.7%

0.4%

18.5%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

Risk Detection and Management of Complications

100.0%

0.0%

no
postnatal /
neonatal
care, 17%

SBA
75%

Place of Delivery (IDHS, 2002/3)

0.0%

40.0%

KN1 &
KN2, 83%

2005

72.6% 74.5% 73.8% 74.7% 77.5%

Pregnancy Risk Detection


and Management of Complications
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%

detected by
community

detected by
health provider

maternal
complications

denominator=20% reported
pregnancies

0.9%

45.4%

10.2%

denominator=all pregnant
w omen

0.2%

9.1%

2.1%

Overall, less than 1% of this total number of women was detected as being at risk by community members and 45% were detected by a health provider (denominator adjusted, applicable to
reporting districts only).
About 10% of all expected maternal complications (20% of pregnancies) were managed by the
health care system at primary or tertiary levels of care. The national target for obstetric complications management is 60% by 2007 and 80% by 2010. Central Kalimantan is far below national
expectations on this indicator.
Management of neonatal complications (estimated to be 25% of newborn) appears to be even lower.
While the national target for 2007 is 60%, increasing to 80% in 2010, Central Kalimantan reports
managing less than 3% of all expected neonatal complications.

SBA 67.2% 72.3% 69.2% 72.1% 74.9%

Provincial Reproductive Health & MPS Profile of Indonesia

139

CENTRAL KALIMANTAN
Maternal and Neonatal Deaths
There were 42 maternal deaths reported in Central Kalimantan in 2005, 1% of all reported maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 89 / 100,000 live
births. This is far smaller than national estimates
(MMR=230, range 58 to 440, WHO/UNICEF/UNFPA, 2000 or MMR=307, IDHS, 2002/3) and suggests under-reporting.

Hospital Management of Maternal and Neonatal Complications


Causes of Maternal Deaths, 2005
bleeding
53%

other /
unknown
21%

eclampsia
21%
infection
5%

The predominant cause of maternal death


(deaths / 100,000 reported newborn)
in Central Kalimantan is bleeding, though
eclampsia plays a significant role. Key in120
104
100
89
terventions to reduce risk of hemorrhage
79
80
69
should be emphasized (iron deficiency ane60
mia control, trained midwives, appropriate
38
40
use of oxytocics in active management of
20
3rd stage as per national policy, access to
0
safe blood transfusion/fluid replacement).
2001
2002
2003
2004
2005
Women with signs or symptoms of hypertensive disorders of pregnancy should be
treated properly and actively referred to specialist care at a hospital, since early delivery by c-section is the most effective measure to prevent progression to eclampsia and death.
Maternal Mortality Ratio 2001-05

It should be noted that 21% of all maternal deaths are not attributed to any immediate cause of
death. More importance should be attached to correctly diagnosing and recording causes of
maternal deaths in order to more closely track progress toward effective management of obstetric
complication and identify potential interventions to reduce maternal mortality.
The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based
on reported data, Central Kalimantan has a neonatal mortality rate of only 4.7 compared to a national estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that
the Central Kalimantan data on neonatal mortality are accurate enough to utilize as an outcome
indicator. According to IDHS 2002/2003, the neonatal mortality rate is 22/1000 births. This province need some effort to achive the 2009 target, 15/1000 births.
The ratio of early to late neonatal deaths suggests some errors in data reporting. Over 97% of
neonatal deaths are reported to have occurred before 7 days. In Indonesia overall, about threequarters of neonatal deaths occur in the first 7 days of life suggesting the importance of improving
quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis, and management of low birth
weight newborn).
The reported stillbirth rate is 7.3 / 1000 estimated deliveries in Central Kalimantan compared to
the national estimate of 17.

140

HOSPITAL CASES
OB/GYN cases treated at hospital
(includes normal deliveries)
Complicated OB/GYN cases treated
at hospital 2
Case fatality rate 3
Hospital admissions due to abortion
Caesarean sections

Number

% of Hospital
Cases

973

--

551

56.6

0.9

169
324

17.4
33.3

% Coverage
(reported pregnancies) 1
1.8% of all pregnancies
-10.0% of reported maternal
deaths (50 in 2004) occurred in
hospital
-0.6% of all deliveries

Denominators from 2004 data were pregnancies: 54,469; deliveries: 51,099.


Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1
2

Reported data from hospitals in Central Kalimantan indicate that nearly 2% of all deliveries occur in
hospital. About 57% of these deliveries are classified as complicated.
The case fatality rate for complications among
hospital deliveries is low at 0.9%, but only 10% of
all reported maternal deaths occurred in the hospital.

Obstetric Complications at Hospital 2004

abortion
31%

other /
unknown
27%

bleeding
18%
eclampsia
21%

infection
3.3%

Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
Over 17% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion practices in Central Kalimantan. About 33% of all deliveries in hospital are by caesarean
section. The c-section rate over all deliveries in the province is 0.6% and suggests that there are
some women delivering outside of hospitals who would have had better outcomes if delivered by
c-section. Internationally, from 5-15% of women are expected to require delivery by c-section for
optimal maternal/neonatal outcome.

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet

Provincial Reproductive Health & MPS Profile of Indonesia

CENTRAL KALIMANTAN

2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.
4. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they
drop out?
5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric and complication.
6. Investigate the possible reasons behind low birth registration rates and develop strategies
to encourage higher registration rates among the community, health providers, and bureaucrats.
7. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
8. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
9. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
10. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


11. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.

BEONC UNMET NEED ACCORDING TO STANDARDS


Total
pop.

District
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Ktw. Barat
196,098
Lamandau
48,676
Sukamara
34,729
Ktw. Timur
285,222
Katingan
125,945
Seruyan
91,838
Kapuas
327,882
Pulang Pisau
114,709
Gunung Mas
84,480
Barito Selatan
116,144
Barito Timur
78,103
Barito Utara
109,584
Murung Raya
83,235
Kota Palangka Raya 170,587
TOTAL
1,867,232

WHO rec#
Total Unmet
Unmet
Pop. / ommended
BEONC Need (MOH:
need
BEONC coverage
in 2005 4 / district)
(WHO)
(1 / 125,000)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
Up to 56

Not reported

need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.

--

COVERAGE OF MIDWIFE PERSONNEL


District
Total reported deliveries

1
2
3
4
5
6
7
8
9
10
11
12
13
14

Ktw. Barat
Lamandau
Sukamara
Ktw. Timur
Katingan
Seruyan
Kapuas
Pulang Pisau
Gunung Mas
Barito Selatan
Barito Timur
Barito Utara
Murung Raya
Kota Palangka Raya

TOTAL

5,785
1,207
938
8,001
3,305
2,892
8,696
2,974
2,255
2,911
1,840
2,665
1,988
4,645

----------------

Total APN midwives

25
1
5
0
4
0
5
0
0
0
0
0
0
0
40
50,102
(1 / 1253 deliveries)

2
1
1
2
1
1
3
1
1
1
1
1
1
1
18

----------------

Total LSS midwives

Not reported

--

12. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
13. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Provincial Reproductive Health & MPS Profile of Indonesia

141

CENTRAL KALIMANTAN
KEY INDICATORS AND NATIONAL TARGETS

Central Kalimantan
2001

2005 *

ANC1 (K1)

91

90

ANC4 (K4)

73

SBA deliveries
Postpartum / Neonatal visit (KN1)

National Target
2007

2010

78

84

95

67

75

82

90

77

83

83

90

Risk detection of pregnant women by community

Not reported

0.9

Obstetric complications managed

Not reported

10.2

60

80

Neonatal complications managed

Not reported

2.8

60

80

Caesarian section rate (% of hospital deliveries)*

34

33

Caesarian section rate (% of reported deliveries)*

1.0

0.6

Hospital OB/GYN cases as % of all pregnancies*

2.9

1.8

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

69

89

* c-section and hospital case data from 2004.

142

Provincial Reproductive Health & MPS Profile of Indonesia

SOUTH
KALIMANTAN

he total population of South Kalimantan is 3.2 million, accounting for about 1.5% of the total population in Indonesia, and nearly 27% of the population in Kalimantan. South Kalimantan is divided
into 13 districts (11 kabupaten + 2 Kota [cities]) with a total
of 1957 villages. The capital is Banjarmasin.

GEOGRAPHY
Total land area (km2)
Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

38,884
13
11
2
127
1957

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

South Kalimantan has a lower urban population (42%) and


far lower poor population (7%) compared to the national
average. Adult female literacy is higher than the national rate at 92%.

The total fertility rate (3.0) and crude birth rate (22.4) are similar to the national average. The
modern contraceptive prevalence rate is also similar (56%) and the percentage of young women
who have begun childbearing is slightly higher (12.5%). Among all contraceptive users, most
women choose oral contraceptives (46%) or injection (40%).
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005)
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6
2

South Kalimantan
3,244,976
42
7
92
74
Male: 59
Female: 63
1.66
760,620 3
3.0
22.4
12.5
56.2
9.3

National

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1
2

South Kalimantan reports 25 hospitals; 13 public and 12 private. Public hospitals appear to be
well-staffed with specialists, but private hospitals have far fewer specialists.

Only 7 of the 12 public hospitals are certified as


providers of Comprehensive Emergency Obstetric
and Neonatal Care (CEONC) with only five districts
reporting at least one. Eight districts report none
(Banjarmasin, Banjarbaru, Banjar, Hulu Sungai Selatan, Hulu Sungai Tengah, Hulu Sungai
Utara, Balangan, Tana Bumbu).

Contraceptive Methods Used


(IDHS 2002/3)

injection,
40%

traditional
methods, 3%

pill, 46%

IUD, 2%
implant, 5%

condom, 1%

permanent,
3%

South Kalimantan did not report any data on total


puskesmas (primary health centers), number of general practitioners or puskesmas with beds or
BEONC level standards in 2004 or 2005.
2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

13

12

Hospitals with CEONC 1

Not reported

In-hospital OBGYN
In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in
Puskesmas
Puskesmas with bed

24
19

2
2

Puskesmas BEONC

Not reported 3

1 CEONC hospital / district

--

<1 / district
1 / 500,000 pop.

(WHO minimum standard:


one / 500,000 pop.)
---

1 / 3142 pregnant women


1 / 3529 newborn

Not reported 2

One PHC / 30,000 pop.

--

Not reported

--

--

Not reported

-4 / district

--

(WHO minimum standard:


One / 125,000 pop.)

--

Comprehensive Emergency Obsetric and Neonatal Care, 24 hour service.


The last available number of puskesmas from health data reports was 189 in 2002.
3
The last available number of BEONC puskesmas from health data reports was 15 in 2003.
1
2

Health Facilities
South Kalimantan reports 25 hospitals; 13 public and 12 private. Public hospitals appear to be

Provincial Reproductive Health & MPS Profile of Indonesia

143

SOUTH KALIMANTAN
well-staffed with specialists, but private hospitals have far fewer specialists.
Only 7 of the 12 public hospitals are certified as providers of Comprehensive Emergency Obstetric and Neonatal Care (CEONC) with only five districts reporting at least one. Eight districts report
none (Banjarmasin, Banjarbaru, Banjar, Hulu Sungai Selatan, Hulu Sungai Tengah, Hulu
Sungai Utara, Balangan, Tana Bumbu).
South Kalimantan did not report any data on total puskesmas (primary health centers), number of
general practitioners or puskesmas with beds or BEONC level standards in 2004 or 2005.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


The current World Health Organization (WHO) recommended standard for BEONC facilities is 1
for every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least
four BEONC facilities for each district.
Though BEONC data were not reported in 2004 or 2005, for every district to have 4 BEONC,
South Kalimantan should have 52 BEONC facilities. However, according to the population size of
South Kalimantan, the total recommended number of BEONC facilities is only 28.
One immediate step would be to review the actual number of BEONC puskesmas in the province,
then identify districts with more than 125,000 population for each BEONC as priority districts for
additional training. The first goal should be to reach at least 28 well-distributed BEONC facilities, and then to increase that number toward 52, with special emphasis on areas with limited
access to CEONC centers. The cost per puskesmas team (3 persons) to be trained in BEONC
is 9.3 million (3.1 per person).

HEALTH PERSONNEL
2001
2005
% Change
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general
practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)

17
15

22
18

29%
20%

176

Not reported

--

119

Not reported

--

2274

Not reported

--

Midwives living in the village


(One / village)

1485

934

37%

Midwives with a kit

1485

934

37%

Midwives trained in APN

Not reported

44

--

Midwives trained in LSS


Total TBA
Trained TBA
TBA with kit

Not reported
Not reported
Not reported
Not reported

0
Not reported
Not reported
Not reported

-----

--

-48% of villages
have village midwife
1 / 3474 population
5% of midwives
(living in village)
----

Number

Ratio of reported
/ estimated 1

Reported pregnancies

82,680

2.52% of total population

101.2

Reported deliveries

76,329

93.5% of reported pregnancies

100.0

Reported newborn

74,107

97.1% of reported deliveries

--

DENOMINATORS FOR KEY


INDICATORS

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.

Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Health Personnel
South Kalimantan reports having one Ob/Gyn per 147,000 population and one pediatrician per
180,000 population. Total number of GPs is not reported, nor is total number of midwives. However less than half (48%) of all villages are reported to have a midwife living in the village, and this
coverage has decreased by 37% since 2001. The proportion of APN-trained midwives (5%) is
low (calculated using the number of village midwives as the denominator). The proportion trained
in BEONC was not reported.

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in South Kalimantan of 22.4 (BPS, 2000), the reported pregnancies are
higher (1%) than the estimated pregnancies, and reported deliveries are equal to the estimated
deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries is valid and
consistent with the country overall, suggesting that the reported events are reasonably accurate.

144

Antenatal Care Coverage


Among reported pregnancies, 91% of the women attended at least one antenatal visit (ANC1).
This drops to 75% coverage of 4 total antenatal visits (ANC4), which is below the 2007 target of
84%. Although ANC1 coverage is relatively good, the difference between ANC4 and ANC1 shows
that over 13,000 women who have accessed antenatal care once do not obtain the minimum
standard of 4 antenatal visits. These women are either not adhering to the recommended antenatal schedule or are accessing ANC too late to reach 4 visits. Quality of care, community awareness, and logistical accessibility factors likely account for these missed opportunities. Over 7000
pregnant women never accessed any antenatal care in South Kalimantan.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of an-

Provincial Reproductive Health & MPS Profile of Indonesia

SOUTH KALIMANTAN
tenatal care provided in South Kalimantan.
Antenatal Care Coverage 2005
Almost all (94%) women report having an abdominal examination; more than 84% report
ANC1 & 4
75%
having their weight and blood pressure measured. More than 83% received iron tablets,
ANC1 only
no ANC
16%
but only 38% report being informed of signs
9%
of pregnancy complications and 20% gave a
blood sample. These data show that critical
components of antenatal care are often not
provided, and the overall quality of antenatal care should be examined more closely.

nurse, while nearly 42% are delivered by a TBA, relative or other person. Similarly, only 9% deliver
at a health facility, while over 90% deliver at home. These data are not consistent with SBA coverage rates reported through the HIS.

There is minimal variation in reported antenatal coverage by most districts.

Postpartum (Neonatal) Care Coverage

There were two districts, Balangan (61%) and Tanah Bumbu (55%), reporting lower rates of
SBA coverage than the provincial average.
There has been no trend toward increasing antenatal care coverage between 2001 and 2005.
SBA coverage may have slightly increased over this time.

Skilled Birth Attendance

Postpartum / Neonatal Care


Coverage 2005

no SBA
19%

KN1
(KN2 not
reported),
87%

100.0%
80.0%
60.0%

SBA
81%

40.0%

More than 4 out of 5 (81%) of all reported deliveries are attended by a skilled
health professional (SBA=skilled birth attendant). This leaves more than 14,500
women delivering without any skilled birth
attendant. The national target for skilled
birth attendance is 82% by 2007 and 90%
by 2010; South Kalimantan is very close
to this expectation.
More than 4 out of 5 (81%) of all reported
deliveries are attended by a skilled health
professional (SBA=skilled birth attendant).
This leaves more than 14,500 women
delivering without any skilled birth attendant. The national target for skilled birth
attendance is 82% by 2007 and 90% by
2010; South Kalimantan is very close to
this expectation.

40.0%

no
postnatal /
neonatal
care, 13%

20.0%
0.0%

public health private health


facility
facility

80.0%
60.0%

Place of Delivery (IDHS, 2002/3)

Skilled Birth Attendant Coverage


2005

Birth Registration and Postnatal Care (IDHS, 2002/3)

home

other /
missing

South Kalimantan

5.9%

3.1%

90.2%

0.7%

Indonesia

9.2%

30.5%

59.0%

1.2%

20.0%
0.0%

birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

South Kalimantan

36.4%

73.6%

9.5%

5.1%

11.8%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

The IDHS estimates that only 36% of all births are officially registered in South Kalimantan, much
lower than the national average. About 87% of all reported newborn attend the first neonatal visit
(KN1); data on the 2nd visit was not reported (data submitted were identical to the 1st visit). The
IDHS estimates slightly lower rates of early postpartum/neonatal care attendance and similar
rates of missing care altogether (12%).

Assistance During Delivery (IDHS, 2002/3)


60.0%
40.0%
20.0%
0.0%

Ob/Gyn or
GP

midw ife or
nurse

TBA

relative or
other

nobody

South Kalimantan

4.4%

53.0%

40.3%

1.6%

0.6%

Indonesia

11.0%

55.3%

31.5%

1.3%

1.1%

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005
100.0%
50.0%
0.0%
k4

2001

2002

2003

2004

2005

78.8% 75.4% 75.7% 72.5% 74.6%

SBA 78.0% 78.7% 80.0% 80.9% 80.9%

Women in South Kalimantan are slightly less likely to deliver with a doctor or nurse/midwife compared to the Indonesian average. Only 4% are attended by a doctor and 53% by a midwife or

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring
progress toward making pregnancy safer
is the rate of pregnant women detected as
at risk by the community, including cadres, TBAs or other lay persons (i.e. nonhealth professionals). Indonesia adopted
that 20% of all pregnant women will need
medical attention during pregnancy or delivery, or almost 16,000 pregnant women
in South Kalimantan annually (20% of all
pregnant women reported).

Pregnancy Risk Detection

(management of complications not reported)

60.0%
40.0%
20.0%
0.0%

detected by
community

detected by
health provider

denominator=20% reported
pregnancies

24.4%

55.5%

denominator=all pregnant
w omen

4.7%

10.8%

maternal
complications

Overall, only 24% of this total number of women was detected as being at risk by community
members, though 80% were detected by a health provider (denominator adjusted, applicable to
reporting districts only).

Provincial Reproductive Health & MPS Profile of Indonesia

145

SOUTH KALIMANTAN
Management of maternal and neonatal complications was not reported. The national target for
obstetric or neonatal complications management is 60% by 2007 and 80% by 2010.

Maternal and Neonatal Deaths


There were 59 maternal deaths reported in South
Kalimantan in 2005, more than 1% of all reported
maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 80 / 100,000 live
births. This is smaller than national estimates
(MMR=230, range 58 to 440, WHO/UNICEF/UNFPA, 2000 or MMR=307, IDHS, 2002/3) and suggests under-reporting.

Causes of Maternal Deaths, 2005


bleeding
54%
other /
unknown
14%

eclampsia
32%

Maternal Mortality Ratio 2001-05

The predominant causes of maternal


(deaths / 100,000 reported newborn)
death in South Kalimantan are bleed133
140
117
ing and eclampsia. Key interventions
109
120
101
100
to reduce risk of hemorrhage should be
80
80
emphasized (iron deficiency anemia con60
trol, trained midwives, appropriate use
40
of oxytocics in active management of 3rd
20
0
stage as per national policy, access to
2001
2002
2003
2004
2005
safe blood transfusion/fluid replacement).
Women with signs or symptoms of hypertensive disorders of pregnancy should be
treated properly and actively referred to specialist care at a hospital, since early delivery by c-section is the most effective measure to prevent progression to eclampsia and death.
It should be noted that 14% of all maternal deaths are not attributed to any immediate cause of
death. Although this is actually a low rate of unassigned deaths compared to other provinces,
it is still critical to reduce it even further in order to more closely track progress toward effective management of obstetric complication and identify potential interventions to reduce maternal
mortality.
The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based
on reported data, South Kalimantan has a neonatal mortality rate of only 3.6 compared to a national estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that
the South Kalimantan data on neonatal mortality are accurate enough to utilize as an outcome
indicator. According to IDHS 2002/2003, the neonatal mortality rate is 23/1000 births. This province need some effort to achive the 2009 target, 15/1000 births.
The ratio of early to late neonatal deaths suggests some errors in data reporting. Over 92% of
neonatal deaths are reported to have occurred before 7 days. In Indonesia overall, about threequarters of neonatal deaths occur in the first 7 days of life suggesting the importance of improving
quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis, and management of low birth

146

weight newborn).
The reported stillbirth rate is 5.1 / 1000 estimated deliveries in South Kalimantan compared to the
national estimate of 17.

Hospital Management of Maternal and Neonatal Complications


Reported data from hospitals in South Kalimantan
indicate that only slightly more than 1% of all deliveries occur in hospital. More than 58% of these
deliveries are classified as complicated.

Obstetric Complications at Hospital 2004


abortion
38%

The case fatality rate for complications among hospital deliveries is high at 2.5% (WHO>1%), but only
2% of all reported maternal deaths occurred in the
hospital.

other /
unknown
30%

bleeding
12%

eclampsia
17%
infection
2.8%

Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
Number

% of Hospital
Cases

% Coverage
(reported pregnancies) 1

1172

--

1.4% of all pregnancies

683

58.3

--

Case fatality rate 3

17

2.49

Hospital admissions due to abortion


Caesarean sections

262
526

22.4
44.9

HOSPITAL CASES
OB/GYN cases treated at hospital
(includes normal deliveries)
Complicated OB/GYN cases treated
at hospital 2

2.3% of reported maternal deaths


(75 in 2004) occurred in hospital
-0.7% of all deliveries

Denominators from 2004 data were pregnancies: 81,553; deliveries: 76,329.


Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1
2

Over 22% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion
practices in South Kalimantan. About 45% of all deliveries in hospital are by caesarean section.
The c-section rate over all deliveries in the province is 0.7% and suggests that there are some
women delivering outside of hospitals who would have had better outcomes if delivered by csection. Internationally, from 5-15% of women are expected to require delivery by c-section for
optimal maternal/neonatal outcome.

Provincial Reproductive Health & MPS Profile of Indonesia

SOUTH KALIMANTAN
13. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Coverage of health personnel and service inputs


1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.
4. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they
drop out?
5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery or obstetric complication.
6. Investigate the possible reasons behind low birth registration rates and develop strategies
to encourage higher registration rates among the community, health providers, and bureaucrats.
7. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
8. Improve the management of obstetric and neonatal complications. Community awareness
of pregnancy risk, and active commitment to ensuring good referral systems could contribute significantly toward even safer deliveries.
9. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
10. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


11. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.

BEONC UNMET NEED ACCORDING TO STANDARDS


District
1
2
3
4
5
6
7
8
9
10
11
12
13

Banjarmasin
Banjarbaru
Banjar
Tapin
Hulu Sungai Selatan
Hulu Sungai Tengah
Hulu Sungai Utara
Balangan
Tabalong
Barito Kuala
Tanah Laut
Tanah Bumbu
Kota Baru

WHO rec#
Total Unmet
Unmet
Pop. / ommended
Total pop. BEONC Need (MOH:
need
BEONC coverage
in 2005 4 / district)
(WHO)
(1 / 125,000)
566,664
148,256
460,541
147,383
203,301
233,887
218,024
106,122
187,383
263,443
248,371
205,302

256,299
TOTAL 3,244,976

Not reported

Recommendations

42

(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
Up to 52

---------------

5
1
4
1
2
2
2
1
2
2
2
2
2
28

-------------

---

COVERAGE OF MIDWIFE PERSONNEL


Total reported deDistrict
Total APN midwives Total LSS midwives
liveries
1 Banjarmasin

2 Banjarbaru

3
4
5
6
7
8
9
10
11
12
13

Banjar
Tapin
Hulu Sungai Selatan
Hulu Sungai Tengah
Hulu Sungai Utara
Balangan
Tabalong
Barito Kuala
Tanah Laut
Tanah Bumbu
Kota Baru

TOTAL

13,253
3,384

2
2

11,144
3,197
4,839

2
2
2

5,407
2,622
4,174

2
2
2

5,508

6,707

5,441
5,212
5,441
76,329

Not reported

20

2
2
2
44
(1 / 1735 deliveries)

--

12. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.

Provincial Reproductive Health & MPS Profile of Indonesia

147

SOUTH KALIMANTAN
KEY INDICATORS AND NATIONAL TARGETS

South Kalimantan
2001

2005 *

ANC1 (K1)

94

91

ANC4 (K4)

79

SBA deliveries

National Target
2007

2010

75

84

95

78

81

82

90

Postpartum / Neonatal visit (KN1)

90

87

83

90

Risk detection of pregnant women by community

27

24

Not
reported
Not
reported

Not
reported
Not
reported

60

80

60

80

Caesarian section rate (% of hospital deliveries)

26

45 *

Caesarian section rate (% of reported deliveries)

1.4

0.7 *

Hospital OB/GYN cases as % of all pregnancies

5.3

1.4 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

133

80

Obstetric complications managed


Neonatal complications managed

* c-sections and hospital cases from 2004 data.

148

Provincial Reproductive Health & MPS Profile of Indonesia

EAST
KALIMANTAN

he total population of East Kalimantan is 2.75


million, accounting for over 1% of the total population in Indonesia, and nearly 23% of the population in Kalimantan. East Kalimantan is divided
into 13 districts (9 kabupaten + 4 Kota [cities]) with a total
of 1352 villages. The capital is Samarinda.

GEOGRAPHY
Total land area (km2)
Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

194,849
13
9
4
124
1352

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

East Kalimantan has a far higher urban population (62%)


and lower poor population (11%) compared to the national average. Adult female literacy is higher than the national rate at 93%.
SOCIAL DEMOGRAPHY

2,750,369
62
11
93
12
Male: 67
Female: 71
2.77
644,690 3
2.8
24.1
14.0
52.3
7.0

Life expectancy at birth (2002) 2


Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

National

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population,
using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

Health Facilities
HEALTH FACILITIES

East Kalimantan

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2

contraceptive users, most women choose injection (39%) or oral contraceptives (35%). Other
commonly used methods include IUD (10%), traditional methods (7%), and tubal ligation/vasectomy (7%).

2005
Public Private

Contraceptive Methods Used


(IDHS 2002/3)
injection,
39%

traditional
m ethods, 7%

pill, 35%

perm anent, IUD, 10%


7%
condom , 1%

im plant, 2%

Coverage

Rows bordered in red are below minimum standard


Total hospitals (general)

12

33

Hospitals with CEONC 1

12

Not reported

In-hospital OBGYN

26

12

--

1 / 1866 pregnant women

In-hospital pediatricians

28

Not reported

--

1 / 2341 newborn

-1 CEONC hospital / district


(WHO minimum standard:
one / 500,000 pop.)

<1 / district
> 2 / 500,000 pop.

Puskesmas
(primary health centers)

178

One PHC / 30,000 pop.

1 / 15,452 pop.

General practitioner in
Puskesmas

177

--

--

Puskesmas with bed

59

--

33% of all puskesmas

Puskesmas BEONC

Not reported in
2004 or 2005

The total fertility rate (2.8) and crude birth


rate (24.1) are similar to the national average. The modern contraceptive prevalence
rate is slightly lower (52%) and the percentage of young women who have begun childbearing is also higher (14%). Among all

Indonesia minimum
standard

4 / district
(WHO minimum standard:
One / 125,000 pop.)

--

Comprehensive Emergency Obsetric and Neonatal Care, 24 hour service.

East Kalimantan reports 45 hospitals, over three-quarters of them private. Public hospitals appear to be well-staffed with specialists, but private hospitals have far fewer specialists.
All the public hospitals (12) are certified as providers of Comprehensive Emergency Obstetric and
Neonatal Care (CEONC) with only one district reporting none (Penajam P. Utara). Some private
hospitals may provide CEONC service, but there are no data reported from private hospitals on
this indicator.

Provincial Reproductive Health & MPS Profile of Indonesia

149

EAST KALIMANTAN
East Kalimantan has 178 puskesmas (primary health centers) with an equal number of general
practitioners (177). One-third (33%) of all puskesmas are reported to have beds for in-patient
care.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


The number of puskesmas having received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC) was not reported in 2004 and 2005. The current World Health
Organization (WHO) recommended standard for BEONC facilities is 1 for every 125,000 people.
Indonesia has adopted this indicator, but translated it to mean at least four BEONC facilities for
each district.
For every district to have 4 BEONC, East Kalimantan should have 52 BEONC facilities. However,
according to the population size of East Kalimantan, the total recommended number of BEONC
facilities is only 21.
One immediate step would be to review the actual number of BEONC puskesmas in the province,
then identify districts with more than 125,000 population for each BEONC as priority districts for
additional training. The first goal should be to reach at least 21 well-distributed BEONC facilities,
and then to increase that number toward 52, with special emphasis on areas with limited access
to CEONC centers. The cost per puskesmas team (3 persons) to be trained in BEONC is IDR
9.3 million (3.1 per person).

Health Personnel
The total specialists in East Kalimantan is not reported, but according to specialists in hospital, the
there would be one OB/Gyn or pediatrician for every 75,000 - 100,000 population. Coverage of
GPs meets the recommended standard. Population coverage of midwives also meets the standard. However less than 15% of all villages are reported to have a midwife living in the village,
and this coverage has decreased by more than 50% since 2001. The proportion of APN-trained
midwives was not calculated due to under-reporting, and the proportion trained in BEONC was
not reported at all.

Primary Health Care Indicators

2001

2005

%
Change

Coverage

Rows bordered in red are below minimum standard


OB/GYNs

Not reported

Not reported

--

Pediatricians

Not reported

Not reported

--

Primary health center general


practitioners
(One GP / 30,000 pop.)

227 1

185

19%

Nurses trained in ANC

1900 1

Not reported

--

Total midwives
(One / 3000 pop.)

1141

1234

8%

1 / 2229 population

Midwives living in the village


(One / village)

435 2

207 3

52%

15% of villages have village midwife

Midwives with a kit

457 2

Not reported

--

--

Midwives trained in APN

Not reported

94

--

Not calculated due to


under-reporting.

Midwives trained in LSS

Not reported

Not reported

--

--

Total TBA

3694

1973

47%

Trained TBA

3148

1370

56%

69% of all TBA

TBA with kit

177

493

179%

25% of all TBA

1 / 14,867 population

Four of 12 districts (Bontang, Kutai Barat, Nunukan, Malinau) did not report this indicator.
Six of 12 districts (Samarinda, Balikpapan, Bontang, Kutai Barat, Nunukan, Malinau) did not report this indicator.
3
Two of 13 districts (Samarinda, Balikpapan) did not report this indicator.
4
Only 3 districts reported this indicator (Samarinda, Balikpapan, Tarakan).
1
2

DENOMINATORS FOR
KEY INDICATORS
Reported pregnancies
Reported deliveries
Reported newborn

Number

71,684
68,056
65,543

2.61% of total population\


94.9% of reported pregnancies
96.3% of reported deliveries

Ratio of reported /
estimated 1
97.4
97.8
--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

than estimated or the population is lower than reported.

The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in East Kalimantan of 24.1 (BPS, 2000), the reported pregnancies are
lower (3%) than the estimated pregnancies, and reported deliveries are similarly lower (2%) than
estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries is
valid and consistent with the country overall, suggesting that the reported events are reasonably
accurate. Likely explanations for this slightly lower number of reported pregnancies and deliveries compared to the expected number may be that the crude birth rate in East Kalimantan is lower

150

HEALTH PERSONNEL
(minimum standard)

Antenatal Care Coverage


Among reported pregnancies, 89% of the women attended at least one antenatal visit (ANC1).
This drops to 79% coverage of 4 total antenatal visits (ANC4), which is below the 2007 target of
84%. Although ANC1 coverage is relatively good, the difference between ANC4 and ANC1 shows
that over 7000 women who have accessed antenatal care once do not obtain the minimum standard of 4 antenatal visits. These women are either not adhering to the recommended antenatal

Provincial Reproductive Health & MPS Profile of Indonesia

EAST KALIMANTAN
schedule or are accessing ANC too late to reach
4 visits. Quality of care, community awareness,
and logistical accessibility factors likely account for
these missed opportunities. Nearly 8000 pregnant
women never accessed any antenatal care in East
Kalimantan. (Note: Three districts, Berau, Bulungan, and Nunukan, were excluded from calculation of ANC1, and two from ANC4 coverage due to
over-reporting of coverage >108%).

Antenatal Care Coverage 2005

There has been a slight trend toward increasing coverage of antenatal care by
about 8 percentage points, and a slightly
larger increase in SBA coverage (about
12 percentage points) between 2001 and
2005.

ANC1 & 4
79%

no ANC
11%

ANC1 only
10%

50.0%
0.0%

2001

2002

2003

2004

2005

70.1% 77.3% 78.8% 78.5% 78.5%

SBA 61.2% 68.1% 68.6% 72.3% 73.3%

Postpartum (Neonatal) Care Coverage


The IDHS estimates that over70% of all births are officially registered in East Kalimantan, much
higher than the national average. About 78% of all reported newborn attend the first and second
neonatal visits (KN1, KN2) and 3% attends KN1 only. The IDHS estimates slightly higher rates of
postpartum/neonatal care attendance and slightly lower rates of missing care altogether (14%).
Postpartum / Neonatal Care
Coverage 2005

There is minimal variation in reported antenatal coverage by most districts.

no
postnatal /
neonatal
care, 19%

Skilled Birth Attendant Coverage


2005

Nearly three-quarters (73%) of all reported deliveries are attended by a skilled health professional (SBA=skilled birth attendant). This leaves
more than 18,000 women delivering without any
skilled birth attendant. The national target for
skilled birth attendance is 82% by 2007 and 90%
by 2010; East Kalimantan is behind this
expectation.

no SBA
27%

SBA
73%

40.0%
20.0%
0.0%

KN1 only,
3%

In Indonesia one of the indicator measuring progress toward making pregnancy


safer is the rate of pregnant women detected as at risk by the community, including cadres, TBAs or other lay persons
(i.e. non-health professionals). Indonesia
adopted that 20% of all pregnant women
will need medical attention during pregnancy or delivery, or over 14,000 pregnant
women in East Kalimantan annually (20%
of all pregnant women reported).

Place of Delivery (IDHS, 2002/3)


50.0%
40.0%
30.0%
20.0%
10.0%
public health
facility

private health
facility

home

other / missing

East Kalimantan

12.7%

32.3%

53.3%

1.7%

Indonesia

9.2%

30.5%

59.0%

1.2%

Assistance During Delivery (IDHS, 2002/3)


80.0%

birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

East Kalimantan

70.4%

79.2%

3.3%

3.1%

14.4%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

Pregnancy Risk Detection


(Management of Complications Not Reported)
80.0%
60.0%
40.0%
20.0%
0.0%

detected by
community

detected by
health provider

denominator=20% reported
pregnancies

8.6%

79.8%

denominator=all pregnant
w omen

1.7%

16.0%

maternal
complications

Overall, only 9% of this total number of women was detected as being at risk by community
members, though 80% were detected by a health provider (denominator adjusted, applicable to
reporting districts only).

60.0%
40.0%
20.0%
0.0%

80.0%

Risk Detection and Management of Complications

60.0%

0.0%

Birth Registration and Postnatal Care (IDHS, 2002/3)


60.0%

KN1 &
KN2, 78%

Skilled Birth Attendance

There were four districts, Kutai Kertanegara (56%), Kutai Barat (51%),
Kutai Timur (53%) and Nunukan (49%),
reporting lower rates of SBA coverage
compared to the provincial average.

100.0%

k4

The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in East Kalimantan. Almost all (97%) women report having an abdominal
examination; more than 92% report having their weight and blood pressure measured. More
than 81% received iron tablets, but only 37% report being informed of signs of pregnancy complications and 44% gave a blood sample. These data show that critical components of antenatal
care are often not provided, and the overall quality of antenatal care should be examined more
closely.

Women in East Kalimantan are slightly


more likely to deliver with a doctor or
nurse/midwife compared to the Indonesian average. Nearly 14% are attended
by a doctor and 66% by a midwife or
nurse. Only 18% are delivered by a TBA,
relative or other person. Similarly, 45%
deliver at a health facility (mostly private),
and 53% deliver at home.

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005

Ob/Gyn or
GP

midw ife or
nurse

TBA

relative or
other

East Kalimantan

13.5%

65.7%

17.9%

0.5%

0.6%

Indonesia

11.0%

55.3%

31.5%

1.3%

1.1%

nobody

Management of maternal and neonatal complications was not reported. The national target for
obstetric or neonatal complications management is 60% by 2007 and 80% by 2010.

Provincial Reproductive Health & MPS Profile of Indonesia

151

EAST KALIMANTAN
Maternal and Neonatal Deaths

Hospital Management of Maternal and Neonatal Complications

There were 58 maternal deaths reported in East Kalimantan in 2005, more than 1% of all reported
maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 88 / 100,000
live births. This is smaller than national estimates
(MMR=230, range 58 to 440, WHO / UNICEF/ UNCauses of Maternal Deaths, 2005
FPA, 2000 or MMR=307, IDHS, 2002/3) and sugbleeding
40%
gests under-reporting.

Reported data from hospitals in East Kalimantan indicate that nearly 8% of all deliveries occur in
hospital. Nearly 41% of these deliveries are classified as complicated.

The predominant cause of maternal death in East


Kalimantan is bleeding, though eclampsia plays a
significant role. Key interventions to reduce risk
of hemorrhage should be emphasized
(iron deficiency anemia control, trained
midwives, appropriate use of oxytocics in
active management of 3rd stage as per na140
tional policy, access to safe blood transfu120
100
sion/fluid replacement). Women with signs
80
or symptoms of hypertensive disorders of
60
pregnancy should be treated properly and
40
20
actively referred to specialist care at a
0
hospital, since early delivery by c-section
is the most effective measure to prevent
progression to eclampsia and death.

eclampsia
33%

other /
unknown
22%

HOSPITAL CASES

infection
5%

Maternal Mortality Ratio, 2001-05


(deaths / 100,000 reported newborn)
(maternal deaths not reported in 2003)

113

88

% of Hospital
% Coverage
Cases
(reported pregnancies) 1

5600

--

7.9% of all pregnancies

Complicated OB/GYN cases treated at


hospital 2

2348

41.9

--

0.26

7.6% of reported maternal


deaths (79 in 2004) occurred in hospital

Hospital admissions due to abortion

1296

23.1

--

Caesarean sections

1580

28.2

2.3% of all deliveries

Denominators from 2004 data were pregnancies: 71,253; deliveries: 67,792.


Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1
2

2001

2002

2003

2004

2005

It should be noted that 22% of all maternal deaths are not attributed to any immediate cause of
death. More importance should be attached to correctly diagnosing and recording causes of
maternal deaths in order to more closely track progress toward effective management of obstetric
complication and identify potential interventions to reduce maternal mortality.
The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based
on reported data, East Kalimantan has a neonatal mortality rate of only 5.2 compared to a national
estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the
East Kalimantan data on neonatal mortality are accurate enough to utilize as an outcome indicator. According to IDHS 2002/2003, the neonatal mortality rate is 20/1000 births. This province
need some effort to achive the 2009 target, 15/1000 births.
The ratio of early to late neonatal deaths is consistent with the expected ratio. Over 81% of
neonatal deaths are reported to have occurred before 7 days, suggesting the importance of improving quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g.
resuscitation, infection prevention, early detection and treatment of sepsis, and management of
low birth weight newborn).

Hospital data do not allow for more detailed analyObstetric Complications at Hospital 2004
sis of how long after admission the mother died.
abortion
This information would reflect whether interven56%
tions needed to reduce maternal deaths should
other /
unknown
emphasize hospital practices / quality of care or
25%
bleeding
eclampsia
10%
9%
community preparedness in recognizing risk and
making timely referrals. The status of maternal and
infection
0.1%
neonatal mortality audits is not reported in the HIS
data, but should be tracked closely by individual
hospitals, districts and provinces and would be an important indicator to monitor nationally.
Over 23% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion
practices in East Kalimantan. About 28% of all deliveries in hospital are by caesarean section.
The c-section rate over all deliveries in the province is 0.6% and suggests that there are some
women delivering outside of hospitals who would have had better outcomes if delivered by csection. Internationally, from 5-15% of women are expected to require delivery by c-section for
optimal maternal/neonatal outcome.

The reported stillbirth rate is 4.3 / 1000 estimated deliveries in East Kalimantan compared to the
national estimate of 17.

152

Number

OB/GYN cases treated at hospital (includes normal deliveries)

Case fatality rate 3

122

104

The case fatality rate for complications among hospital deliveries is low at 0.3%, but only 8% of
all reported maternal deaths occurred in the hospital.

Provincial Reproductive Health & MPS Profile of Indonesia

EAST KALIMANTAN
Recommendations

BEONC UNMET NEED ACCORDING TO STANDARDS

Coverage of health personnel and service inputs

District

2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.
4. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they
drop out?
5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
8. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
9. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

1
2
3
4
5
6
7
8
9
10
11
12
13

Samarinda
Balikpapan
Kutai Kertanegara
Kutai Barat
Kutai Timur
Bontang
Pasir
Berau
Bulungan
Tarakan
Malinau
Nunukan
Penajam P.Utara

TOTAL

485,375
147,468
168,321
116,302
171,773
140,731
96,598
152,299
47,258
106,915
118,219
485,375
147,468
2,750,369

Not reported

1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.

WHO recom#
Total Unmet
Unmet
Total popPop. / mended covBEONC Need (MOH:
need
ulation
BEONC
erage
in 2005 4 / district)
(WHO)
(1 / 125,000)

--

(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
Up to 52

COVERAGE OF MIDWIFE PERSONNEL


Total reported
District
deliveries
1
2
3
4
5
6
7
8
9
10
11
12
13

Samarinda
Balikpapan
Kutai Kertanegara
Kutai Barat
Kutai Timur
Bontang
Pasir
Berau
Bulungan
Tarakan
Malinau
Nunukan
Penajam P.Utara

Data quality and reporting

TOTAL

11,726
3,614
4,159
2,827
4,303
3,372
2,219
4,467
2,757
1,199
2,968
11,726
3,614

68,056

---------------

5
3
3
1
1
1
1
1
1
1
1
1
1
21

Total APN midwives

1
5
Not reported
Not reported
Not reported
Not reported
Not reported
Not reported
Not reported
3
Not reported
Not reported
Not reported

---------------

Total LSS midwives

Not reported

--

10. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
11. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
12. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Provincial Reproductive Health & MPS Profile of Indonesia

153

EAST KALIMANTAN
East Kalimantan

National Target

2001

2005 *

2007

2010

ANC1 (K1)

85

89

ANC4 (K4)

70

78

84

95

SBA deliveries

61

73

82

90

Postpartum / Neonatal visit (KN1)

75

82

83

90

Risk detection of pregnant women by community

84 1

8.6

KEY INDICATORS AND NATIONAL TARGETS

Obstetric complications managed

Not reported Not reported

60

80

Neonatal complications managed

Not reported Not reported

60

80

Caesarian section rate (% of hospital deliveries)

23

28 *

Caesarian section rate (% of reported deliveries)

2.8

2.3 *

Hospital OB/GYN cases as % of all pregnancies

12.4

7.9 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

113

88

This high rate of risk detection by community members may be a reporting error. The same indicator was only 11% in 2002.
* c-section and hospital case data from 2004.
1

154

Provincial Reproductive Health & MPS Profile of Indonesia

NORTH
SULAWESI

he total population of North Sulawesi is 2.2 million, accounting for about 1% of the total population in Indonesia, and nearly 14% of the population in Sulawesi. North Sulawesi is divided into
9 districts (6 kabupaten + 3 Kota [cities]) with a total of
1280 villages. The capital is Manado.
North Sulawesi has a lower urban population (43%) and
far lower poor population (9%) compared to the national
average. Adult female literacy is very high at 99%.

GEOGRAPHY

Total land area (km2)


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

13,931
9
6
3
122
1280

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

The total fertility rate (2.6) is similar to the national average, and crude birth rate (20.9) is slightly
lower. The modern contraceptive prevalence rate is higher (66%) but the percentage of young
women who have begun childbearing is similar (10.5%). Among all contraceptive users, most
women choose injection (34%), oral contraceptives (28%), IUD (17%), or implants (12%).
SOCIAL DEMOGRAPHY
Total population (2005) 1
Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

North Sulawesi
2,215,152
43
9
99
140
Male: 69
Female: 73
1.37
519,230 3
2.6
20.9
10.0
66.4
4.4

National
220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1
2

Health Facilities
North Sulawesi reports at least 17 hospitals, about
two-thirds of them private (many districts did not report this indicator, however). All reported hospitals
appear to be well-staffed with specialists.

Contraceptive Methods Used


(IDHS 2002/3)
injection,
34%

pill, 28%

IUD, 17%

All public hospitals (6 only) are certified as providers


traditional
of Comprehensive Emergency Obstetric and Neona- methods,
permanent,
5%
3%
tal Care (CEONC) with only four districts reporting at
least one. Five districts either did not report, or have
none (Tomohon, Minahasa Selatan, Minahasa Utara, Bolaang Mongondow, Talaud).
implant, 12%

North Sulawesi reports 56 puskesmas (primary health centers) in 5 of 9 districts; four districts
did not report this indicator. Among puskesmas in five districts, there are 76 puskesmas-based
general practitioners (four districts did not report). Among the four reporting districts, 29% of
puskesmas are reported to have beds for in-patient care.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


There were only 14 puskesmas (among five reporting districts) which have received training
and certification in Basic Emergency Obstetric and Neonatal Care (BEONC). The current World
Health Organization (WHO) recommended standard for BEONC facilities is 1 for every 125,000
people. Indonesia has adopted this indicator, but translated it to mean at least four BEONC
facilities for each district. For every district to have 4 BEONC, North Sulawesi should have 36
BEONC facilities. However, according to the population size of North Sulawesi, the total recommended number of BEONC facilities is only 17.
One immediate step would be to review the actual number of BEONC puskesmas in the province,
then identify districts with more than 125,000 population for each BEONC as priority districts for
additional training (Minahasa Selatan, Minahasa Utara, Bolaang Mongondow). The first goal
should be to reach at least 17 well-distributed BEONC facilities, and then to increase that number toward 36, with special emphasis on areas with limited access to CEONC centers. The cost
per puskesmas team (3 persons) to be trained in BEONC is IDR 9.3 million (3.1 per person).

Provincial Reproductive Health & MPS Profile of Indonesia

155

NORTH SULAWESI
HEALTH FACILITIES

2005
Public

Indonesia minimum standard

Private

Coverage

Rows bordered in red are below minimum standard


Total hospitals (general)

Hospitals with CEONC 1

62

62

12 3

Not reported

-1 CEONC hospital /
district

<1 / district
(WHO minimum stan- >1 / 500,000 pop.
dard:
one / 500,000 pop.)

In-hospital OBGYN

62

14 3

--

1 / 2476 pregnant women

In-hospital pediatricians

14

--

1 / 2158 newborn

One PHC / 30,000


pop.

1 / 39,556 pop.

Puskesmas
(primary health centers)

56 4

General practitioner in
Puskesmas

76 5

--

1/ 29,147 pop.

Puskesmas with bed

16 6

--

29% of all puskesmas

4 / district
Puskesmas BEONC

14 7

25% of all puskesmas

Average 1.6/district; 4 of 9
(WHO minimum stan- districts have none
dard:
One / 125,000 pop.)
1 / 158,225 pop.

HEALTH PERSONNEL
(minimum standard)

2001

2005

% Change

Coverage

Rows bordered in red are below minimum standard


OB/GYNs

Not reported

17 1

--

Pediatricians

Not reported

20

--

Primary health center general practitioners


(One GP / 30,000 pop.)

263

161 2

39%

Nurses trained in ANC

309

193 3

Not calculated
due to under-reporting

Total midwives
(One / 3000 pop.)

1308

706

46%

1 / 3138 population

Midwives living in the village


(One / village)

1198

596

50%

47% of villages have


village midwife

Midwives with a kit

1198

540

55%

1 / 4102 population

Midwives trained in APN

Not reported

90

--

13% midwives

Midwives trained in BEONC

Not reported

97

--

1 / 22,837 population

Total TBA

6447

398 2

Trained TBA

4009

199 2

TBA with kit

293

179

Not calculated
due to under-reporting

54%
1 / 7946 population

50% of all TBA


45% of all TBA

Two (Bolaang Mongondow, Talaud) of nine districts did not report this indicator, or were zero.
Four (Minahasa Utara, Bolaang Mongondow, Sangihe, Talaud) of nine districts did not report this indicator. Population
coverage denominator adjusted for non reporting districts.
3
Six (Minahasa, Minahasa Selatan, Minahasa Utara, Bolaang Mongondow, Sangihe,Talaud) of nine districts did not report
this indicator.
4
Seven (Manado, Minahasa, Minahasa Selatan, Minahasa Utara, Bolaang Mongondow, Sangihe,Talaud) of nine districts
did not report this indicator.
5
Four (Minahasa, Minahasa Selatan, Minahasa Utara, Sangihe) of nine districts did not report this indicator.
1

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.


2
Five (Tomohon, Minahasa Selatan, Minahasa Utara, Bolaang Mongondow, Talaud) of nine districts did not report this
indicator, or were zero.
3
Two (Bolaang Mongondow, Talaud) of nine districts did not report this indicator, or were zero.
4
Four (Minahasa Utara, Bolaang Mongondow, Sangihe, Talaud) of nine districts did not report this indicator, or were zero.
5
Five (Minahasa Selatan, Minahasa Utara, Bolaang Mongondow, Sangihe, Talaud) of nine districts did not report this
indicator, or were zero.
6
Five (Tomohon, Minahasa Utara, Bolaang Mongondow, Sangihe, Talaud) of nine districts did not report this indicator, or
were zero.
7
Four (Tomohon, Minahasa Selatan, Bolaang Mongondow, Sangihe) of nine districts did not report this indicator, or were
zero.
1

Health Personnel
North Sulawesi reports having one Ob/Gyn for every 130,000 population and one pediatrician for
every 110,000 population. Coverage of GPs meets the recommended standard, despite lack of
reporting from four districts. Population coverage of midwives is slightly below the standard and
less than half (47%) of all villages report having a midwife living in the village. Midwives have
decreased 46% since 2001, and village midwife coverage has decreased 50% since 2001. The
proportion of APN-trained midwives (13%) is low, but is an unreliable indicator because only 2 of
9 districts reported. A similar number of midwives were reported to have received BEONC training.

156

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in North Sulawesi of 24.8 (BPS, 2000), the reported pregnancies are
less than 1% higher than the estimated pregnancies, and reported deliveries about 3% lower
than estimated deliveries. The proportion of deliveries to pregnancies is also a bit lower than
expected and the district totals for reported newborn was nearly identical to reported deliveries.
These discrepancies suggest that there may be some problems with the counting or reporting
of vital events in North Sulawesi. For indicator calculation in this profile, reported pregnancies
and deliveries were retained, but total newborn were estimated. The multiplier used to estimate
newborn (reported deliveries x 96.2%) was calculated from all reported deliveries and newborn
in Indonesia.

Provincial Reproductive Health & MPS Profile of Indonesia

NORTH SULAWESI
DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported
/ estimated 1

Reported pregnancies

49,517

2.24% of total population

96.4

Reported deliveries

44,866

90.6% of reported pregnancies

92.3

43,161

Not applicable

--

Estimated newborn

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
2
Estimated newborn (96.2% of deliveries) was used instead of reported newborn because because reported births was
nearly100% of reported deliveries. A multiplier (deliveries x 96.2%) was used, reflecting the proportion of reported newborn
to reported deliveries in Indonesia.
1

Antenatal Care Coverage


Among reported pregnancies, 90% of the women
Antenatal Care Coverage 2005
attended at least one antenatal visit (ANC1). This
drops to 77% coverage of 4 total antenatal visits
ANC1 & 4
(ANC4), which is far below the 2007 target of 84%.
77%
Although coverage of ANC1 care is relatively good,
no ANC
ANC1 only
10%
the difference between ANC4 and ANC1 is large
13%
with over 6000 women (10%) who have accessed
antenatal care once but do not obtain the minimum
standard of 4 antenatal visits. These women are either not adhering to the recommended antenatal schedule or are accessing ANC too late to reach
4 visits. Quality of care, community awareness, and logistical accessibility factors likely account
for these missed opportunities. Nearly 5000 pregnant women never accessed any antenatal
care in North Sulawesi.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in North Sulawesi. Almost all (97%) women report having an abdominal
examination; more than 83% report having their weight and blood pressure measured. More
than 92% received iron tablets, but only 35% report being informed of signs of pregnancy complications and 52% gave a blood sample. These data show that critical components of antenatal
care are often not provided, and the overall quality of antenatal care should be examined more
closely.
There is minimal variation in reported antenatal coverage by most districts.

Skilled Birth Attendance


Two districts reported unusually low SBA coverage which was not consistent with reported SBA
coverage in those districts in 2004. Therefore, when they were excluded from the 2005 SBA

coverage calculation, more than 81% of all reported


deliveries are attended by a skilled health professional (SBA=skilled birth attendant). This leaves nearly
8400 women delivering without a skilled birth attendant. The national target for skilled birth attendance
is 82% by 2007 and 90% by 2010; North Sulawesi is
within reach of this expectation.
According to IDHS data, women in North
Sulawesi are more likely to deliver with
a doctor or nurse/midwife compared to
the Indonesian average. More than 1 in
4 women (26%) are attended by a doctor
and nearly 60% by a midwife or nurse,
while only 12% are delivered by a TBA, relative or other person. Similarly, nearly half
(49%) deliver at a health facility (mostly
private), while the remaining (49%) deliver
at home.

Skilled Birth Attendant Coverage


2005
no SBA
19%
SBA
81%

Place of Delivery (IDHS, 2002/3)


60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%

public health private health


facility
facility

home

other /
missing

North Sulaw esi

16.9%

31.7%

48.7%

2.6%

Indonesia

9.2%

30.5%

59.0%

1.2%

Assistance During Delivery (IDHS, 2002/3)


80.0%
60.0%
40.0%

The two districts excluded from the SBA


coverage calculation were Bolaang Mongondow (38% in 2005; 78% in 2004) and
Sangihe (29% in 2005; 90% in 2004).

20.0%
0.0%

There has been no trend toward increasing antenatal care coverage between 2001
and 2005. SBA coverage may have increased by about 2 percentage points over
this time, but the trend is not consistent.

Ob/Gyn or
GP

midw ife or
nurse

TBA

relative or
other

nobody

North Sulaw esi

26.0%

59.7%

12.0%

0.0%

0.2%

Indonesia

11.0%

55.3%

31.5%

1.3%

1.1%

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005
(data for 2002 not reported by district)
100.0%
50.0%
0.0%
k4

2001 2002 2003 2004 2005


77.3% 77.3% 80.7% 86.4% 77.7%

SBA 78.8% 74.3% 81.2% 86.5% 81.3%

interpret. Four districts were excluded from KN

Postpartum (Neonatal) Care Coverage


The IDHS estimates that only 43% of all births
are officially registered in North Sulawesi, much
lower than the national average. Data on KN1
and KN2 attendance are questionable, and not
consistent with 2004 data. About 82% of all reported newborn attend the first and second neonatal visits (KN1, KN2); data KN1 attendance
are difficult to interpret. Four districts were excluded from KN1 calculations due to unrealisti-

Provincial Reproductive Health & MPS Profile of Indonesia

Postpartum / Neonatal Care


Coverage 2005

KN1 &
KN2, 82%
no
postnatal /
neonatal
care, 18%

157

NORTH SULAWESI
cally low or high reported rates: Minahasa
Selatan 12%, Minahasa Utara 108%,
Bolaang Mongondow 40% and Sangihe
30%). Four districts were excluded from
KN2 calculations due to low reported rates,
or non-reporting (Tomohon 14%, Minahasa Selatan 5%, Bolaang Mongondow
and Sangihe not reported).

Birth Registration and Postnatal Care (IDHS, 2002/3)


80.0%
60.0%
40.0%
20.0%
0.0%

birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

North Sulaw esi

43.1%

78.8%

3.2%

4.0%

13.4%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

The IDHS estimates slightly higher rates of early postpartum/neonatal care attendance and slightly lower rates of missing care altogether (13%).

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring
progress toward making pregnancy safer
is the rate of pregnant women detected as
at risk by the community, including cadres,
TBAs or other lay persons (i.e. non-health
professionals). Indonesia adopted that
20% of all pregnant women will need medical attention during pregnancy or delivery,
or almost 10,000 pregnant women in North
Sulawesi annually (20% of all pregnant
women reported).

Pregnancy Risk Detection

(management of complications not reported)

80.0%
60.0%
40.0%
20.0%
0.0%

detected by
community

detected by
health provider

denominator=20% reported
pregnancies

20.8%

72.8%

denominator=all pregnant
w omen

4.2%

14.6%

maternal
complications

Overall, only 21% of this total number of women was detected as being at risk by community
members, though 73% were detected by a health provider (denominator adjusted, applicable to
reporting districts only). The community rate of risk detection is unreliable, however, because
only 3 districts reported this indicator.
Management of maternal complications was not reported, though 41% of expected neonatal complications (25% of live births) was reported as managed (3 of 9 districts did not report, however).
The national target for obstetric or neonatal complications management is 60% by 2007 and 80%
by 2010.

Maternal and Neonatal Deaths


There were 69 maternal deaths reported in North Sulawesi in 2005, nearly 2% of all reported
maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 160 / 100,000 live
births. This is smaller than national estimates (MMR=230, range 58 to 440, WHO/UNICEF/UNFPA, 2000 or MMR=307, IDHS, 2002/3) and suggests under-reporting.
The predominant cause of maternal death in North Sulawesi is bleeding, though eclampsia
plays a significant role. Key interventions to reduce risk of hemorrhage should be emphasized

158

(iron deficiency anemia control, trained


midwives, appropriate use of oxytocics in
active management of 3rd stage as per national policy, access to safe blood transfusion/fluid replacement). Women with signs
or symptoms of hypertensive disorders of
pregnancy should be treated properly and
actively referred to specialist care at a hospital, since early delivery by c-section is the
most effective measure to prevent progression to eclampsia and death.
It should be noted that 29% of all maternal
deaths are not attributed to any immediate
cause of death. More importance should
be attached to correctly diagnosing and recording causes of maternal deaths in order
to more closely track progress toward effective management of obstetric complication and identify potential interventions to
reduce maternal mortality.

Causes of Maternal Deaths, 2005


bleeding
49%
eclampsia
16%

other /
infection
6%

unknown
29%

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)
(no data reported in 2002)

200
180
160
140
120
100
80
60
40
20
0

179
143

2001

2002

2003

171

2004

160

2005

The number of reported stillbirths and neonatal deaths indicates under-reporting. Based on reported data, North Sulawesi has a neonatal mortality rate of only 9.5 compared to a national
estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the
North Sulawesi data on neonatal mortality are accurate enough to utilize as an outcome indicator.
According to IDHS 2002/2003, the neonatal mortality rate is 16/1000 births. This province need
some effort to achive the 2009 target, 15/1000 births.
The ratio of early to late neonatal deaths suggests some errors in data reporting. Only 54% of
neonatal deaths are reported to have occurred before 7 days. In Indonesia overall, about threequarters of neonatal deaths occur in the first 7 days of life suggesting the importance of improving
quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis, and management of low birth
weight newborn).
The reported stillbirth rate is 8.8 / 1000 estimated deliveries in North Sulawesi compared to the
national estimate of 17.

Hospital Management of Maternal and Neonatal Complications


Reported data from hospitals in North Sulawesi indicate that more than 13% of all deliveries occur
in hospital. About 41% of these deliveries are classified as complicated.
The case fatality rate for complications among hospital deliveries is low at 0.4%, but only 15% of
all reported maternal deaths occurred in the hospital.

Provincial Reproductive Health & MPS Profile of Indonesia

NORTH SULAWESI
tion with population size.
Number

% of Hospital
Cases

% Coverage
(reported pregnancies) 1

OB/GYN cases treated at hospital


(includes normal deliveries)

6515

--

13.2% of all pregnancies

Complicated OB/GYN cases treated


at hospital 2

2657

40.8

--

Case fatality rate 3

11

0.41

14.7% of reported maternal


deaths (75 in 2004) occurred
in hospital

Hospital admissions due to abortion

737

11.3

--

Caesarean sections

1478

22.7

3.2% of all deliveries

HOSPITAL CASES

Denominators from 2004 data were pregnancies: 49,516; deliveries: 45,611.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Obstetric Complications at Hospital 2004

(no deaths due to infection reported)


Hospital data do not allow for more detailed analysis of how long after admission the mother died.
other /
unknown
This information would reflect whether interventions
41%
abortion
bleeding
needed to reduce maternal deaths should empha28%
22%
size hospital practices / quality of care or community
eclampsia
9%
preparedness in recognizing risk and making timely
referrals. The status of maternal and neonatal
mortality audits is not reported in the HIS data, but
should be tracked closely by individual hospitals,
districts and provinces and would be an important indicator to monitor nationally.

Over 11% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion practices in North Sulawesi. About 23% of all deliveries in hospital are by caesarean section
which is consistent with the rate of complicated deliveries reported among all hospital deliveries.
The c-section rate over all deliveries in the province is 3.2% which is higher than most provinces,
but still suggests that there are some women delivering outside of hospitals who would have had
better outcomes if delivered by c-section. Internationally, from 5-15% of women are expected to
require delivery by c-section for optimal maternal/neonatal outcome.

3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.
4. I Investigate the reason behind low ANC1 coverage. Why do so many women never access antenatal care? Investigate the reasons behind the difference between ANC4 and
ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they drop out?
5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
8. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
9. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


10. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
11. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
12. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlaProvincial Reproductive Health & MPS Profile of Indonesia

159

NORTH SULAWESI
BEONC UNMET NEED ACCORDING TO STANDARDS
District
1
2
3
4
5
6
7
8
9

Manado
Bitung
Tomohon
Minahasa
Minahasa Selatan
Minahasa Utara
Bolaang Mongondow
Sangihe
Talaud
TOTAL

WHO recTotal
#
Total Unmet
Unmet
Pop. / ommended
popula- BEONC Need (MOH:
need
BEONC coverage
tion
in 2005 4 / district)
(WHO)
(1 / 125,000)
416,771
174,106
87,719
299,492
301,294
176,515
483,294
193,831
82,130
2,215,152

2
2
-5
-1
--4
14

2
2
(4)
0
(4)
3
(4)
(4)
0
7 - 23

208,386
87,053
-59,898
-176,515
--20,533
158,225

1
2
3
4
5
6
7
8
9

Manado
Bitung
Tomohon
Minahasa
Minahasa Selatan
Minahasa Utara
Bolaang Mongondow
Sangihe
Talaud

TOTAL

160

Total reported
deliveries
8,670
3,419
1,791
6,187
5,945
3,010
10,162
4,052

1,630

44,866

1
0
(1)
0
(2)
0
(4)
(2)
0
1 - 10

Total APN midwives


-45
45
------

-90
(1 / 499 deliveries)

North Sulawesi
2001

2005 *

ANC1 (K1)

96

91

ANC4 (K4)

77

SBA deliveries
Postpartum / Neonatal visit (KN1)

National Target
2007

2010

78

84

95

79

81

82

90

88

82

83

90

13.7

20.8

Obstetric complications managed

Not reported

Not reported

60

80

Neonatal complications managed

Not reported

40.9

60

80

Caesarian section rate (% of hospital deliveries)

15.7

22.7 *

Caesarian section rate (% of reported deliveries)

3.3

3.2 *

Hospital OB/GYN cases as % of all pregnancies

19.0

13.2 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

143

160

Risk detection of pregnant women by community

* c-sections and hospital data from 2004.

COVERAGE OF MIDWIFE PERSONNEL


District

3
1
1
2
2
1
4
2
1
17

KEY INDICATORS AND NATIONAL TARGETS

Total BEONC midwives

1
45
45
---3
--

3
97
1 / 463 deliveries)

Provincial Reproductive Health & MPS Profile of Indonesia

CENTRAL
SULAWESI

he total population of Central Sulawesi is over


2.3 million, accounting for 1% of the total population in Indonesia, and 14% of the population
in Sulawesi. Central Sulawesi is divided into 10
districts (9 kabupaten + 1 Kota [cities]) with a total of 1530
villages. The capital is Palu city.
Central Sulawesi has a much lower urban population
(20%) and slightly higher poor population (20%) compared to the national average. Adult female literacy is
also higher at 93%.

Health Facilities

GEOGRAPHY
Total land area (km )

68,090

Number of districts

10

Kabupaten (regencies)

Kota (municipalities)

Kecamatan (sub-districts)

102

Kelurahan/Desa (villages)

1530

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

The total fertility rate (3.2) and crude birth rate (24.4) are higher than the national average. The
modern contraceptive prevalence rate is lower (50%) and the percentage of young women who
have begun childbearing is higher (15.2%). Among all contraceptive users, most women choose
oral contraceptives (35%) or injection (31%). Other common methods include implants (10%),
traditional methods (9%), IUD (9%) or tubal ligation/vasectomy (5%).
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

Central Sulawesi
2,304,002
20
20
93
38
Male: 61
Female: 65
2.01
540,749 3
3.2
24.4
15.2
49.8
10.2

National

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

Central Sulawesi reports 16 hospitals; 10 public and


6 private. All public hospitals report Ob/Gyn and pediatric staff but no private report any specialists.
All of the public hospitals are reported as certified
provider of Comprehensive Emergency Obstetric
and Neonatal Care (CEONC). This leaves two districts with no CEONC coverage: Donggala and Bangkep.

Contraceptive Methods Used


(IDHS 2002/3)

injection,
31%
traditional
methods, 9%

pill, 35%

implant, 10%

permanent, IUD, 9%
5%

2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES
Total hospitals (general)

10

Hospitals with CEONC 1

10

Not reported

In-hospital OBGYN
In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in
Puskesmas
Puskesmas with bed

11

(WHO minimum standard:


one / 500,000 pop.)
-1 / 5424 pregnant women

11

--

1 / 4923 newborn

123 2

One PHC / 30,000 pop.

1 / 18,732 pop.

119 2

--

1/ 19,361 pop.

59 2

--

48% of all puskesmas


37% of all puskesmas

-1 CEONC hospital / district

4 / district
Puskesmas BEONC

1
1

45

(WHO minimum standard:


One / 125,000 pop.)

1 / district
>2 / 500,000 pop.

Average 4-5/district; all


districts report at least one
1 / 51,200 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.


One district (Kt. Palu) did not report this indicator.

Provincial Reproductive Health & MPS Profile of Indonesia

161

CENTRAL SULAWESI
Central Sulawesi reports 123 puskesmas (primary health centers) which meets the recommended standard (Kt Palu did not report this indicator). There also appear to be adequate general
practitioners (119) in puskesmas. Nearly one-half (48%) of puskesmas are reported to have beds
for in-patient care.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


One-third (37%) of all puskesmas, 45 facilities total, were reported to have received training and
certification in Basic Emergency Obstetric and Neonatal Care (BEONC). This is an average of
4-5 per district, and all districts report at least one (see BEONC unmet need table at end of this
profile).
The current World Health Organization (WHO) recommended standard for BEONC facilities is 1
for every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least
four BEONC facilities for each district. For every district to have 4 BEONC, Central Sulawesi
should have 48 BEONC facilities. However, according to population size, the minimum total
recommended number is 18.
Central Sulawesi is only 3 BEONC facilities short of meeting the higher standard, which ranks
among the highest of all provinces on this indicator. The cost per puskesmas team (3 persons) to
be trained in BEONC is IDR 9.3 million (3.1 per person).

Health Personnel
HEALTH PERSONNEL
2001
2005
% Change
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in BEONC
Total TBA
Trained TBA
TBA with kit

Not reported
Not reported

11
11

---

168

132 1

21%

Not reported

42 2

--

1859

1467

21%

809

864

7%

616
Not reported
Not reported
4032
3568
3568

277 3
145
142
796 4
571 5
215 6

55%
--Not calculated
due to under-reporting

162

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.
Assuming a crude birth rate in Central Sulawesi of 24.4 (BPS, 2000), the reported pregnancies
are about 4% lower than the estimated pregnancies, and reported deliveries are about 3% lower
than estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries
is valid and consistent with the country overall, suggesting that the reported events are reasonably accurate. Likely explanations for this lower number of reported pregnancies and deliveries
compared to the expected number may be that the crude birth rate in Central Sulawesi is lower
than estimated or the population is lower than reported.
DENOMINATORS FOR
KEY INDICATORS

Number

Ratio of reported /
estimated 1

Reported pregnancies

59,659

2.59% of total population

95.6

Reported deliveries

56,992

95.5% of reported pregnancies

95.6

Reported newborn

54,149

95.1% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

1 / 17,455 population

Antenatal Care Coverage


1 / 1571 population
56% of villages have
village midwife
1 / 7316 population
10% midwives
1 / 16,225 population
72% of all TBA
27% of all TBA

One district (Kt Palu) did not report this indicator.


Six districts (Kt Palu, Donggala, Parigi Mautong, Buol, Banggai, Bangkep) did not report this indicator.
3
Two districts (Poso, Tojo Una Una) did not report this indicator. Coverage denominator adjusted.
4
Five districts (Kt Palu, Donggala, Parigi Mautong, Morowali, Bangkep) did not report this indicator.
5
Five districts (Kt Palu, Donggala, Parigi Mautong, Tojo Una Una, Bangkep) did not report this indicator.
6
Seven districts (Kt Palu, Donggala, Parigi Mautong, Buol, Tojo Una Una, Banggai, Bangkep) did not report this indicator.
1

Central Sulawesi reports having one Ob/Gyn and one pediatrician for every 200,000 population.
Coverage of GPs meets the recommended standard, as does coverage of midwives, though the
total number of midwives has declined since 2001. However only 56% of all villages report having a midwife living in the village. Only 10% of all midwives are reported to be APN-trained, and
a similar number have received BEONC training.

Among reported pregnancies, 87% of the women


Antenatal Care Coverage 2005
attended at least one antenatal visit (ANC1). This
drops to 78% coverage of 4 total antenatal visits
ANC1 & 4
(ANC4), which is below the 2007 target of 84%. The
78%
difference between ANC4 and ANC1 suggests that
over 5000 women who have accessed antenatal
ANC1 only
no ANC
9%
13%
care once but do not obtain the minimum standard
of 4 antenatal visits. These women are either not
adhering to the recommended antenatal schedule
or are accessing ANC too late to reach 4 visits. Quality of care, community awareness, and logistical accessibility factors likely account for these missed opportunities. Nearly 8000 pregnant
women never accessed any antenatal care in Central Sulawesi.

Provincial Reproductive Health & MPS Profile of Indonesia

CENTRAL SULAWESI
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in Central Sulawesi. Over 92% of women report having an abdominal
examination; more than 81% report having their weight measured, and 77% report having their
blood pressure measured. Only 65% received iron tablets, 31% report being informed of signs
of pregnancy complications and 30% report giving a blood sample. These data show that critical
components of antenatal care are often not provided, and the overall quality of antenatal care
should be examined more closely.
There is minimal variation in reported antenatal coverage by most districts, however, one district
(Bangkep) reported lower rates of ANC1 (62%) and the exact same number for ANC4 (62%).

Postpartum (Neonatal) Care Coverage


The IDHS estimates that only 24% of all births are officially registered in Central Sulawesi, far
lower than the national average. About 78% of all reported newborn attend the first and second
neonatal visits (KN1, KN2) and 2% attends KN1 only. The IDHS estimates higher rates of postpartum/neonatal care attendance and slightly lower rates of missing care altogether (15%).
Birth Registration and Postnatal Care (IDHS, 2002/3)

Postpartum / Neonatal Care

80.0%

Coverage 2005

60.0%
40.0%

KN1 &
KN2, 78%

Skilled Birth Attendance

20.0%

no
postnatal /
neonatal
care, 22%

Place of Delivery (IDHS, 2002/3)

Skilled Birth Attendance Coverage


2005

100.0%

0.0%

KN1 only,
2%

birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

Central Sulaw esi

24.1%

76.5%

6.6%

2.0%

14.9%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

80.0%

no SBA
26%

60.0%
40.0%

SBA
74%

Risk Detection and Management of Complications

20.0%
0.0%

Nearly three-quarters (74%) of all reported


deliveries are attended by a skilled health
professional (SBA=skilled birth attendant).
This leaves almost 15,000 women delivering without any skilled birth attendant. The
national target for skilled birth attendance
is 82% by 2007 and 90% by 2010; Central
Sulawesi is below this expectation.
Women in Central Sulawesi are less likely
to deliver with a doctor or nurse/midwife
compared to the Indonesian average. Only
8% are attended by a doctor and 46% by a
midwife or nurse. More than 45% are delivered by a TBA, relative or other person.
Only 17% deliver at a health facility, while
82% deliver at home. This is among the
highest rates of home delivery among all
provinces in Indonesia.

public health private health


facility
facility

home

other /
missing

Central Sulaw esi

12.1%

4.6%

82.0%

1.4%

Indonesia

9.2%

30.5%

59.0%

1.2%

Assistance During Delivery (IDHS, 2002/3)


60.0%
40.0%
20.0%
0.0%

Ob/Gyn or
GP

midw ife or
nurse

TBA

Central Sulaw esi

7.7%

46.3%

Indonesia

11.0%

55.3%

relative or
other

nobody

41.4%

4.1%

0.0%

31.5%

1.3%

1.1%

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005
100.0%
50.0%
0.0%
k4

2001

2002

2003

2004

2005

76.3% 74.9% 85.4% 77.9% 78.0%

In Indonesia one of the indicator measuring progress toward making pregnancy


safer is the rate of pregnant women detected as at risk by the community, including cadres, TBAs or other lay persons (i.e.
non-health professionals). Indonesia adopted that 20% of all pregnant women will
need medical attention during pregnancy
or delivery, or more than 37,000 pregnant
women in Central Sulawesi annually (20%
of all pregnant women reported).

Pregnancy Risk Detection


and Management of Complications
80.0%
60.0%
40.0%
20.0%
0.0%

detected by
community

detected by
health provider

maternal
complications

denominator=20% reported
pregnancies

19.3%

63.5%

13.0%

denominator=all pregnant
w omen

3.9%

12.7%

2.6%

Overall, only 19% of this total number of women was detected as being at risk by community
members, though 64% were detected by a health provider (denominator adjusted, applicable to
reporting districts only).
Only 13% of maternal complications were reported to have been managed, and 11% of expected
neonatal complications (25% of live births) were reported as managed. The national target for
obstetric or neonatal complications management is 60% by 2007 and 80% by 2010.

SBA 65.7% 69.5% 75.0% 76.1% 74.3%

Maternal and Neonatal Deaths

There is minimal variation in reported SBA coverage by most districts, however, two districts (Toli
Toli 59% and Morowali 62%) did report lower rates of SBA compared to the provincial average.
Antenatal coverage since 2001 shows no consistent increasing coverage, but SBA coverage appears to have increased consistently about 8 percentage points.

There were 89 maternal deaths reported in Central Sulawesi in 2005, over 2% of all reported
maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 164 / 100,000 live
births. This is smaller than national estimates (MMR=230, range 58 to 440, WHO/UNICEF/UNFPA, 2000 or MMR=307, IDHS, 2002/3) and suggests under-reporting.

Provincial Reproductive Health & MPS Profile of Indonesia

163

CENTRAL SULAWESI
The predominant cause of maternal death in Central Sulawesi is bleeding, though eclampsia plays a
significant role. Key interventions to reduce risk of
hemorrhage should be emphasized (iron deficiency
anemia control, trained midwives, appropriate use
of oxytocics in active management of 3rd
stage as per national policy, access to
safe blood transfusion/fluid replacement).
Women with signs or symptoms of hyper250
tensive disorders of pregnancy should be
200
treated properly and actively referred to
specialist care at a hospital, since early
150
delivery by c-section is the most effective
100
measure to prevent progression to ec50
lampsia and death.
0

Causes of Maternal Deaths, 2005

HOSPITAL CASES

bleeding
43%
other /
unknown
26%

OB/GYN cases treated at hospital


(includes normal deliveries)
Complicated OB/GYN cases treated
at hospital 2

eclampsia
24%
infection
7%

Case fatality rate 3

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)
228

198

190

2001

2002

2003

196

2004

Hospital admissions due to abortion


Caesarean sections

2005

It should be noted that 26% of all maternal


deaths are not attributed to any immediate cause of death. More importance should be attached
to correctly diagnosing and recording causes of maternal deaths in order to more closely track
progress toward effective management of obstetric complication and identify potential interventions to reduce maternal mortality.
The number of reported stillbirths and neonatal deaths indicates under-reporting. Based on reported data, Central Sulawesi has a neonatal mortality rate of only 6.5 compared to a national
estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the
Central Sulawesi data on neonatal mortality are accurate enough to utilize as an outcome indicator. According to IDHS 2002/2003, the neonatal mortality rate is 24/1000 births. This province
need some effort to achive the 2009 target, 15/1000 births.

% of Hospital
Cases

% Coverage
(reported pregnancies) 1

2808

--

4.7% of all pregnancies

1563

58.9

--

15

0.96

527
1000

18.8
35.6

14.2% of reported maternal


deaths (106 in 2004) occurred in
hospital
-1.8% of all deliveries

Denominators from 2004 data were estimated pregnancies: 59,506; estimated deliveries: 56,289. Reported pregnancies and
deliveries were not consistent with estimates and appeared invalid.
2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

164

Number

Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or
community preparedness in recognizing risk and
making timely referrals. The status of maternal
and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.

Obstetric Complications at Hospital 2004


other /
unknown
46%
abortion
21%

bleeding
24%
eclampsia
7%
infection
2%

The ratio of early to late neonatal deaths is consistent with the expected ratio. About 82% of
neonatal deaths are reported to have occurred before 7 days, suggesting the importance of improving quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g.
resuscitation, infection prevention, early detection and treatment of sepsis, and management of
low birth weight newborn).

Nearly 19% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion practices in Central Sulawesi. About 36% of all deliveries in hospital are by caesarean
section which is consistent with the rate of complicated deliveries reported among all hospital
deliveries. The c-section rate over all deliveries in the province is less than 2% and suggests that
there are women delivering outside of hospitals who would have had better outcomes if delivered
by c-section. Internationally, from 5-15% of women are expected to require delivery by c-section
for optimal maternal/neonatal outcome.

The reported stillbirth rate is 8.0 / 1000 estimated deliveries in Central Sulawesi compared to the
national estimate of 17.

Recommendations

Hospital Management of Maternal and Neonatal Complications

Coverage of health personnel and service inputs

Reported data from hospitals in Central Sulawesi indicate that nearly 5% of all deliveries occur in
hospital. About 59% of these deliveries are classified as complicated.

1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.

The case fatality rate for complications among hospital deliveries is below 1% (WHO>1%), but
only 14% of all maternal deaths occurred in hospital.

2. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.

164

Provincial Reproductive Health & MPS Profile of Indonesia

CENTRAL SULAWESI
3. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they
drop out?
4. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
5. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
6. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
7. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
8. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities level.

Data quality and reporting


9. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.

BEONC UNMET NEED ACCORDING TO STANDARDS


Total UnWHO rec#
Unmet
Total popmet Need
Pop. / ommended
District
BEONC
need
ulation
(MOH:
BEONC coverage
in 2005
(WHO)
4 / district)
(1/125,000)
10 Bangkep
150,880
5
0
30,176
1
0
TOTAL 2,304,002
45
3
51,200
18
1
COVERAGE OF MIDWIFE PERSONNEL
Total reported
District
deliveries
1 Kt Palu

2
3
4
5
6
7
8
9
10

7,873

17

11,893

30

Parigi Mautong

8,648

16

Poso

3,152

Toli Toli

4,492

66

66

Buol

2,689

12

Tojo Una Una

2,883

Morowali

3,791

Banggai

7,534

Bangkep

4,037

5
145
(1 / 393 deliveries)

5
142
1 / 401 deliveries)

Donggala

TOTAL

10. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
11. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.
BEONC UNMET NEED ACCORDING TO STANDARDS
Total UnWHO rec#
Unmet
Total popmet Need
Pop. / ommended
District
BEONC
need
ulation
(MOH:
BEONC coverage
in 2005
(WHO)
4 / district)
(1/125,000)

56,992

KEY INDICATORS AND NATIONAL TARGETS

Central Sulawesi
2001

2005 *

ANC1 (K1)

86

87

ANC4 (K4)

76

SBA deliveries
Postpartum / Neonatal visit (KN1)

National Target
2007

2010

78

84

95

66

74

82

90

69

78

83

90

Risk detection of pregnant women by community

Not reported

19.3

Obstetric complications managed

Not reported

13.0

60

80

Not reported

11.4

60

80

304,230
457,484

1
6

3
0

304,230
76,247

2
4

1
0

Neonatal complications managed

Parigi Mautong

357,042

71,408

Caesarian section rate (% of hospital deliveries)

22.4

35.6 *

Poso

164,414

32,883

Caesarian section rate (% of reported deliveries)

1.8

1.8 *

Toli Toli

190,698

47,675

Hospital OB/GYN cases as % of all pregnancies

7.6

4.7 *

Buol

109,453

27,363

198

164

Tojo Una Una

113,063

28,266

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

Morowali

166,477

33,295

Banggai

290,261

48,377

1 Kt Palu
2 Donggala

3
4
5
6
7
8
9

Total BEONC midwives

Total APN midwives

* c-sections and hospital data from 2004.

Provincial Reproductive Health & MPS Profile of Indonesia

165

CENTRAL SULAWESI

166

Provincial Reproductive Health & MPS Profile of Indonesia

SOUTH
SULAWESI

he total population of South Sulawesi is nearly 7.7


million, accounting for 3.5% of the total population in Indonesia, and 48% of the population in
Sulawesi. South Sulawesi is divided into 23 districts (20 kabupaten + 3 Kota [cities]) with a total of 2866
villages. The capital is Makasar.
South Sulawesi has a much lower urban population (32%)
and similar poor population (15%) compared to the national average. Adult female literacy is lower at 82%.

GEOGRAPHY

Total land area (km2)


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

46,116
23
20
3
279
2866

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

The total fertility rate (2.6) and crude birth rate (22.9) are similar to the national average. The
modern contraceptive prevalence rate is lower (42%) and the percentage of young women who
have begun childbearing is higher (13.6%). Among all contraceptive users, most women choose
injection (47%), oral contraceptives (27%) or traditional methods (14%).
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

South Sulawesi
7,691,281
32
15
82
136
Male: 67
Female: 71
1.08
1,802,840 3
2.6
22.9
13.6
42.4
11.8

National
220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

Health Facilities
South Sulawesi reports 40 hospitals; 30 public and
10 private. Nearly all public hospitals (25) report Ob/
Gyn staff and two-thirds (20) report having at least
one pediatrician. Only 4 private hospitals report Ob/
Gyn staff, and only 2 report having a pediatrician.
Three-quarters (23) of the public hospitals are reported as certified provider of Comprehensive
Emergency Obstetric and Neonatal Care (CEONC).
HEALTH FACILITIES

2005

Contraceptive Methods Used


(IDHS 2002/3)
injection,
47%
pill, 27%
traditional
methods,
14%
permanent,
3%

implant, 6%

Indonesia minimum
standard

Public Private

IUD, 2%

Coverage

Rows bordered in red are below minimum standard


Total hospitals (general)

30

10

23

Not reported

In-hospital OBGYN

25

--

1 / 6424 pregnant women

In-hospital pediatricians

20

--

1 / 7657 newborn

Hospitals with CEONC

-1 CEONC hospital / district


(WHO minimum standard:
one / 500,000 pop.)

1 / district
>1 / 500,000 pop.

Puskesmas
(primary health centers)

361

One PHC / 30,000 pop.

1 / 21,305 pop.

General practitioner in
Puskesmas

348

--

1/ 22,101 pop.

Puskesmas with bed

170

--

47% of all puskesmas


11% of all puskesmas

4 / district
Puskesmas BEONC

41

(WHO minimum standard:


One / 125,000 pop.)

Average 1 -2 /district; 11
of 23 districts have none
1 / 187,592 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.

Provincial Reproductive Health & MPS Profile of Indonesia

167

SOUTH SULAWESI
This leaves five districts with no CEONC coverage: Jeneponto, Goa, Wajo, Luwu and Luwu
Timur.
South Sulawesi reports 361 puskesmas (primary health centers) which meets the recommended
standard. There is also an adequate number of puskesmas-based general practitioners (348).
Nearly one-half (47%) of puskesmas are reported to have beds for in-patient care.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 11% of all puskesmas, or 41 facilities total, were reported to have received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC). This is an average of 1-2 per
district, though 11 districts report none (see BEONC unmet need table at end of this profile).
The current World Health Organization (WHO) recommended standard for BEONC facilities is
1 for every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at
least four BEONC facilities for each district. For every district to have 4 BEONC, South Sulawesi
should have 102 BEONC facilities. However, according to population size, the minimum total
recommended number is 62.
One immediate step would be to train puskesmas teams in the districts with no BEONC facility
and relatively high population (Bulukumba, Jeneponto, Goa, Wajo, and Pinrang). Next would
be to increase the number of BEONC facilities in all districts toward the total recommended number of 102. The cost per puskesmas team (3 persons) to be trained in BEONC is IDR 9.3 million
(3.1 per person).
HEALTH PERSONNEL
2005
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in BEONC
Total TBA
Trained TBA
TBA with kit

25
18

501

168

South Sulawesi reports having one Ob/Gyn for every 300,000 population and one pediatrician
for every 425,000 population. Coverage of GPs meets the recommended standard. Coverage
of midwives, however, is below the recommended standard. An additional 566 midwives would
be required to meet the standard of 1/3000 population. Only 44% of all villages report having a
midwife living in the village. Over one-third of all midwives (36%) are reported to be APN-trained,
but fewer than 4% have received BEONC training.
Data on these indicators was not reported in South Sulawesi for 2001 and 2002, so changes over time
could not be examined.

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in South Sulawesi of 22.9 (BPS, 2000), the reported pregnancies are
about 5% lower than the estimated pregnancies, and reported deliveries are about 4% lower than
estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries is
valid and consistent with the country overall, suggesting that the reported events are reasonably
accurate. Likely explanations for this lower number of reported pregnancies and deliveries compared to the expected number may be that the crude birth rate in South Sulawesi is lower than
estimated or the population is lower than reported.
DENOMINATORS FOR
KEY INDICATORS
Reported pregnancies
Reported deliveries
Reported newborn

1 / 15,352 population

89 1
1998

1 / 13849 population

1268

44% of villages have village midwife

726
717
75
4139 2
1822 3
1814 4

1 / 10,594 population
36% midwives
-44% of all TBA
44% of all TBA

Number

186,293
177,005
168,453

2.42% of total population


95.0% of reported pregnancies
95.2% of reported deliveries

Ratio of reported / estimated 1


95.3
95.7
--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Eleven districts did not report this indicator (Jeneponto, Bone, Maros, Wajo, Pinrang, Enrekakang, Luwu, Pare-Pare,
Luwu Utara, Luwu Timur, Palopo).
2
Two districts did not report this indicator (Maros, Enrekakang).
3
Four districts did not report this indicator (Jeneponto, Sinjai, Maros, Maskasar)
3
Five districts did not report this indicator (Sinjai, Maros, Enrekakang, Tanatoraja, Luwu Timur)
1

Health Personnel

Antenatal Care Coverage


Among reported pregnancies, 89% of the women
attended at least one antenatal visit (ANC1).
This drops to 70% coverage of 4 total antenatal
visits (ANC4), which is far below the 2007 target
of 84%. Although coverage of ANC1 care is relatively good, the difference between ANC4 and
ANC1 is large with over 36,000 women (19%)

Provincial Reproductive Health & MPS Profile of Indonesia

Antenatal Care Coverage 2005


ANC1 & 4
70%

no ANC
11%

ANC1 only
19%

SOUTH SULAWESI
who have accessed antenatal care once but do not obtain the minimum standard of 4 antenatal
visits. These women are either not adhering to the recommended antenatal schedule or are accessing ANC too late to reach 4 visits. Quality of care, community awareness, and logistical accessibility factors likely account for these missed opportunities. Nearly 20,000 pregnant women
never accessed any antenatal care in South Sulawesi.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in South Sulawesi. Over 96% of women report having an abdominal examination; more than 91% report having their weight and blood pressure measured. Nearly 73%
received iron tablets, but only 15% report being informed of signs of pregnancy complications and
59% gave a blood sample. These data show that critical components of antenatal care are often
not provided, and the overall quality of antenatal care should be examined more closely.
There is minimal variation in reported antenatal coverage by most districts, however, four districts
did have lower rates of ANC1 and ANC4, respectively, compared to the provincial average (Selayar: 80%, 59%; Bone: 79%, 58%; Tanatoraja: 79%, 50%; and Palopo: 76%, 58%).

There is minimal variation in reported SBA coverage by most districts, however, three districts
(Selayar 56%, Bone 44% and Enrekakang 57%) had lower rates of SBA compared to the provincial average.
Antenatal coverage since 2001 show consistent trends toward increasing coverage about 6 percentage points; an increasing trend for SBA coverage was not apparent.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that only 41% of all births are officially registered in South Sulawesi, lower
than the national average. About 72% of all reported newborn attend the first and second neonatal visits (KN1, KN2) and 5% attends KN1 only. The IDHS estimates similar rates of postpartum/
neonatal care attendance and slightly lower rates of missing care altogether (19%).
Birth Registration and Postnatal Care (IDHS, 2002/3)

Postpartum / Neonatal Care


Coverage 2005

80.0%
60.0%

KN1 &
KN2, 72%

Skilled Birth Attendance

20.0%

no
postnatal /
neonatal
care, 23%

Place of Delivery (IDHS, 2002/3)

Skilled Birth Attendant Coverage


2005

40.0%

0.0%

KN1 only,
5%

80.0%

birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

South Sulaw esi

40.8%

76.1%

3.2%

1.4%

19.3%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

60.0%

no SBA
31%

40.0%

SBA
69%

0.0%

Only 69% of all reported deliveries are


attended by a skilled health professional
(SBA=skilled birth attendant). This leaves
almost 56,000 women delivering without
any skilled birth attendant. The national
target for skilled birth attendance is 82%
by 2007 and 90% by 2010; South Sulawesi
is far behind this expectation.
Women in South Sulawesi are less likely to
deliver with a doctor compared to the Indonesian average. Only 7% are attended by
a doctor and 56% by a midwife or nurse.
More than one-third (37%) are delivered by
a TBA, relative or other person. One-third
(35%) deliver at a health facility, while 64%
deliver at home.

Risk Detection and Management of Complications

20.0%
public health private health
facility
facility

home

other /
missing

South Sulaw esi

20.3%

15.1%

63.9%

0.6%

Indonesia

9.2%

30.5%

59.0%

1.2%

Assistance During Delivery (IDHS, 2002/3)


60.0%
40.0%
20.0%
0.0%

Ob/Gyn or
GP

midw ife or
nurse

TBA

South Sulaw esi

6.7%

55.5%

Indonesia

11.0%

55.3%

relative or
other

nobody

31.2%

5.7%

0.5%

31.5%

1.3%

1.1%

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005
100.0%
50.0%
0.0%
k4

2001

2002

2003

2004

2005

63.7% 61.5% 62.6% 68.5% 70.1%

SBA 66.7% 61.7% 61.2% 68.3% 68.6%

In Indonesia one of the indicator measuring


progress toward making pregnancy safer is
the rate of pregnant women detected as at
risk by the community, including cadres,
TBAs or other lay persons (i.e. non-health
professionals). Indonesia adopted that
20% of all pregnant women will need medical attention during pregnancy or delivery,
or more than 37,000 pregnant women in
South Sulawesi annually (20% of all pregnant women reported).

Pregnancy Risk Detection


and Management of Complications
60.0%
40.0%
20.0%
0.0%

detected by
community

detected by
health provider

maternal
complications

denominator=20% reported
pregnancies

26.8%

57.6%

28.4%

denominator=all pregnant
w omen

5.4%

11.5%

5.7%

Overall, only 27% of this total number of women was detected as being at risk by community
members, though 58% were detected by a health provider (denominator adjusted, applicable to
reporting districts only). The community rate of risk detection is unreliable, however, because
only 3 districts reported this indicator.
Only 28% of maternal complications were reported to have been managed, and 35% of expected
neonatal complications (25% of live births) were reported as managed. The national target for
obstetric or neonatal complications management is 60% by 2007 and 80% by 2010.

Provincial Reproductive Health & MPS Profile of Indonesia

169

SOUTH SULAWESI
Hospital Management of Maternal and Neonatal Complications

Maternal and Neonatal Deaths


There were 163 maternal deaths reported
in South Sulawesi in 2005, nearly 4% of all
reported maternal deaths in Indonesia. The
estimated maternal mortality ratio (MMR) is
97 / 100,000 live births. This is far smaller
than national estimates (MMR=230, range
58 to 440, WHO/UNICEF/UNFPA, 2000 or
MMR=307, IDHS, 2002/3) and suggests
under-reporting.

Causes of Maternal Deaths, 2005


bleeding
54%

other /
unknown
24%

infection
6%

eclampsia
16%

Reported data from hospitals in South Sulawesi indicate that just over 2% of all deliveries occur
in hospital. About 53% of these deliveries are classified as complicated.
The case fatality rate for complications among hospital deliveries is low at 0.5% (WHO>1%).
The proportion of maternal deaths occurring in hospital cannot be determined because maternal
deaths were not reported in 2004. Based on the number of death sin 2005, however, it is likely
to be below 10%.
Number

% of Hospital Cases

% Coverage
(reported pregnancies) 1

OB/GYN cases treated at hospital (includes normal deliveries)

4244

--

2.3% of all pregnancies

Complicated OB/GYN cases treated at


hospital 2

2237

52.7

--

12

0.54

Maternal deaths not reported


through HIS in 2004

Hospital admissions due to abortion

1169

27.5

--

Caesarean sections

1378

32.5

0.8% of all deliveries

HOSPITAL CASES

Maternal Mortality Ratio 2001-05


The predominant cause of maternal death
(deaths / 100,000 reported newborn)
in South Sulawesi is bleeding, though ec(not reported in 2004)
lampsia plays a significant role. Key in98
97
97
terventions to reduce risk of hemorrhage
96
95
should be emphasized (iron deficiency ane94
93
92
92
mia control, trained midwives, appropriate
92
91
91
use of oxytocics in active management of
90
89
3rd stage as per national policy, access to
88
safe blood transfusion/fluid replacement).
2001
2002
2003
2004
2005
Women with signs or symptoms of hypertensive disorders of pregnancy should be
treated properly and actively referred to specialist care at a hospital, since early delivery by c-section is the most effective measure to prevent progression to eclampsia and death.

It should be noted that 24% of all maternal deaths are not attributed to any immediate cause of
death. More importance should be attached to correctly diagnosing and recording causes of
maternal deaths in order to more closely track progress toward effective management of obstetric
complication and identify potential interventions to reduce maternal mortality.
The number of reported stillbirths and neonatal deaths indicates under-reporting. Based on reported data, South Sulawesi has a neonatal mortality rate of only 2.9 compared to a national
estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the
South Sulawesi data on neonatal mortality are accurate enough to utilize as an outcome indicator. According to IDHS 2002/2003, the neonatal mortality rate is 12/1000 births. This province is
already over the 2009 target, 15/1000 births.
The ratio of early to late neonatal deaths is consistent with the expected ratio. About 70% of
neonatal deaths are reported to have occurred before 7 days, suggesting the importance of improving quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g.
resuscitation, infection prevention, early detection and treatment of sepsis, and management of
low birth weight newborn).

Case fatality rate 3

Denominators from 2004 data were pregnancies: 183,219; deliveries: 174,891.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or
community preparedness in recognizing risk and
making timely referrals. The status of maternal
and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would be
an important indicator to monitor nationally.

abortion
52%

other /
unknown
26%

bleeding
14%
infection
2.7%

eclampsia
5%

Over 27% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion practices in South Sulawesi. About 33% of all deliveries in hospital are by caesarean section
which is consistent with the rate of complicated deliveries reported among all hospital deliveries.
The c-section rate over all deliveries in the province is less than 1% and suggests that there are
women delivering outside of hospitals who would have had better outcomes if delivered by csection. Internationally, from 5-15% of women are expected to require delivery by c-section for
optimal maternal/neonatal outcome.

The reported stillbirth rate is 3.5 / 1000 estimated deliveries in South Sulawesi compared to the
national estimate of 17.

170

Obstetric Complications at Hospital 2004

Provincial Reproductive Health & MPS Profile of Indonesia

SOUTH SULAWESI
Recommendations

BEONC UNMET NEED ACCORDING TO STANDARDS

Coverage of health personnel and service inputs

WHO recTotal Unmet


Total pop- # BEONC
Pop. / ommended
Need (MOH:
ulation
in 2005
BEONC coverage
4 / district)
(1 / 125,000)

District

1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.

Unmet
need
(WHO)

1 Selayar

114,598

--

2 Bulukumba

656,559

--

3 Banteng

161,776

--

4 Jeneponto

324,928

--

5 Takalar

258,051

258,051

6 Goa

565,252

--

7 Sinjai

219,478

--

8 Bone

686,080

114,347

9 Maros

291,971

--

4. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they
drop out?

10 Pangkep

285,172

71,293

11 Barru

157,680

157,680

12 Soppeng

222,798

37,133

13 Wajo

370,630

--

5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.

14 Sidrap

245,741

--

15 Pinrang

297,306

--

16 Enrekakang

178,658

89,329

17 Luwu

307,306

76,827

18 Tanatoraja

435,696

62,242

1,177,027

168,147

20 Pare-Pare

115,406

115,406

21 Luwu Utara

282,302

282,302

22 Luwu Timur

211,132

--

23 Palopo

125,734

125,734

7,691,281

41

61

187,592

62

32

6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
8. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.

19 Makasar

TOTAL

9. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


10. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
11. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
12. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Provincial Reproductive Health & MPS Profile of Indonesia

171

SOUTH SULAWESI
COVERAGE OF MIDWIFE PERSONNEL
Total reported
District
deliveries
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

Selayar
Bulukumba
Banteng
Jeneponto
Takalar
Goa
Sinjai
Bone
Maros
Pangkep
Barru
Soppeng
Wajo
Sidrap
Pinrang
Enrekakang
Luwu
Tanatoraja
Makasar
Pare-Pare
Luwu Utara
Luwu Timur
Palopo

2,604
8,697
3,907
8,089
7,275
13,054
5,800
16,541
6,348
6,735
3,360
4,259
9,322
5,699
7,756
4,689
8,274
10,054
27,052
2,823
6,427
4,875
3,365

TOTAL

177,005

Total APN
midwives

3
40
19
16
61
129
13
50
30
17
5
22
0
0
2
4
63
36
127
24
45
0
11
717
(1 / 247 deliveries)

Total BEONC
midwives

0
0
0
2
2
34
0
0
0
10
5
0
0
0
0
0
2
2
7
6
0
0
5
75
1 / 2360 deliveries)

South Sulawesi

National Target

2001

2005 *

2007

2010

ANC1 (K1)

87

89

ANC4 (K4)

64

70

84

95

SBA deliveries

67

69

82

90

Postpartum / Neonatal visit (KN1)

75

77

83

90

Risk detection of pregnant women by community

Not reported

26.8

Obstetric complications managed

Not reported

28.4

60

80

Neonatal complications managed

Not reported

35.1

60

80

Caesarian section rate (% of hospital deliveries)

20.0

32.5 *

Caesarian section rate (% of reported deliveries)

1.1

0.8 *

Hospital OB/GYN cases as % of all pregnancies

5.0

2.3 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

91

97

KEY INDICATORS AND NATIONAL TARGETS

* c-sections and hospital data from 2004.

172

Provincial Reproductive Health & MPS Profile of Indonesia

SOUTHEAST
SULAWESI

he total population of Southeast Sulawesi is


nearly 2 million, accounting for 1% of the total
population in Indonesia, and 12% of the population in Sulawesi. Southeast Sulawesi is divided
into 10 districts (8 kabupaten + 2 Kota [cities]) with a total
of 1705 villages. The capital is Kendari city.

GEOGRAPHY

Southeast Sulawesi has a much lower urban population


(23%) and slightly higher poor population (20%) compared to the national average. Adult female literacy is
similar at 88%.

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

Total land area (km2)


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

36,757
10
8
2
133
1705

The total fertility rate (3.6) and crude birth rate (24.8) are higher than the national average. The
modern contraceptive prevalence rate is lower (41%) and the percentage of young women who
have begun childbearing is higher (14.0%). Among all contraceptive users, most women choose
injection (45%) or oral contraceptives (22%). Other common methods include traditional methods
(16%) or implants (10%).
SOCIAL DEMOGRAPHY
Total population (2005) 1
Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

Southeast Sulawesi
1,976,783
23
20
88
55
Male: 63
Female: 67
2.76
463,360 3
3.6
24.8
14.0
40.9
13.4

National
220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table7.
5
BPS 2000
6
IDHS 2002/3
1
2

Health Facilities
Southeast Sulawesi reports only 6 hospitals, all
public. There are 12 Ob/Gyn and 7 pediatricians
reported to be staffing both public and private hospitals, suggesting that the total hospitals reported is
inaccurate.

Contraceptive Methods Used


(IDHS 2002/3)
injection,
45%

traditional
methods,
16%

pill, 22%

implant, 10%

IUD, 3%
permanent,
All of the reported hospitals are certified provider of
condom, 1%
4%
Comprehensive Emergency Obstetric and Neonatal
Care (CEONC). This leaves five districts with no CEONC coverage: Konsel, Kolaka Utara,
Wakatobi, Bombana and Muna.

Southeast Sulawesi reports 123 puskesmas (primary health centers) which meets the recommended standard (two districts did not report this indicator). However far fewer puskesmasbased general practitioners (53) are reported (though six districts did not report). Only 17% of
puskesmas are reported to have beds for in-patient care (six districts not reporting).

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 8% of all puskesmas, 10 facilities total, were reported to have received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC). This indicator may be inaccurate, however, since three districts report some, and the remaining seven all report zero (see
BEONC unmet need table at end of this profile).
The current World Health Organization (WHO) recommended standard for BEONC facilities is 1
for every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least
four BEONC facilities for each district. For every district to have 4 BEONC, Southeast Sulawesi
should have 40 BEONC facilities. However, according to population size, the minimum total
recommended number is 17.
One immediate step would be to review the actual number of BEONC puskesmas in the province
(are there really none in most provinces?), then identify districts with more than 125,000 population for each BEONC as priority districts for additional training (Buton, Muna, Kota Kendari).
The first goal should be to reach at least 1-2 BEONC facilities in each district, and then to increase

Provincial Reproductive Health & MPS Profile of Indonesia

173

SOUTHEAST SULAWESI
that number toward 40. The cost per puskesmas team (3 persons) to be trained in BEONC is IDR
9.3 million (3.1 per person).
2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

Hospitals with CEONC 1

In-hospital OBGYN
In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in
Puskesmas
Puskesmas with bed

6
2

1 CEONC hospital / district


Not re(WHO minimum standard:
ported
one / 500,000 pop.)
6
-5
--

Puskesmas BEONC

--

<1 / district
>1 / 500,000 pop.

Primary Health Care Indicators

1 / 4563 pregnant women


1 / 6864 newborn

The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in Southeast Sulawesi of 20.9 (BPS, 2000), the reported pregnancies
are about 4% lower than the estimated pregnancies, and reported deliveries about 8% lower than
estimated deliveries. The proportion of deliveries to pregnancies is also a bit lower than expected
and the district totals for reported newborn was higher than reported deliveries. These discrepancies suggest that there may be some problems with the counting or reporting of vital events in
Southeast Sulawesi. For indicator calculation in this profile, reported pregnancies and deliveries
were retained, but total newborn were estimated. The multiplier used to estimate newborn (reported deliveries x 96.2%) was calculated from all reported deliveries and newborn in Indonesia.

123 2

One PHC / 30,000 pop.

1 / 16,071 pop.

53 3

--

1/ 37,298 pop.

21 4

--

17% of all puskesmas


8% of all puskesmas
Average 1/district; 7 of 10
districts have none

4 / district
10

(WHO minimum standard:


One / 125,000 pop.)

1 / 197,678 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.


2
Two districts (Wakatobi, Bombana) did not report this indicator.
3
Six districts (Konawe, Buton, Wakatobi, Bombana, Muna, Kota Kendari) did not report this indicator.
4
Six districts (Konawe, Kolut, Buton, Wakatobi, Bombana, Muna) did not report this indicator.
1

Health Personnel

Not reported
Not reported

7
6

---

178

133 1

25%

Not reported

Not reported

--

1520

584 2

62%

829

527

36%

829
Not reported
Not reported
2482
2479
Not reported

551
521
237
Not reported
Not reported
Not reported

33%
------

Two districts (Wakatobi, Bombana) did not report this indicator.


One district (Konawe) did not report this indicator.
3
Only reported by 1-2 districts, so not tabulated here.

174

DENOMINATORS FOR KEY


INDICATORS
Reported pregnancies
Reported deliveries
Estimated newborn 2

1 / 14,863 population

1 / 3385 population
31% of villages have
village midwife
1 / 3588 population
89% midwives
1 / 8341 population
---

Number

54,752
49,944
48,046

2.77% of total population


91.2% of reported pregnancies
96.2% of reported deliveries

Ratio of reported /
estimated 1
100.6
97.0
--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
2
Estimated newborn (96.2% of deliveries) was used instead of reported newborn because there were more reported newborn
than deliveries. A multiplier (deliveries x 96.2%) was used, reflecting the proportion of reported newborn to reported deliveries in Indonesia.
1

HEALTH PERSONNEL
2001
2005
% Change
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general
practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in BEONC
Total TBA
Trained TBA
TBA with kit

Southeast Sulawesi reports having one Ob/Gyn for every 280,000 population and one pediatrician for every 325,000 population. Coverage of GPs meets the recommended standard, though
coverage has declined since 2001. Coverage of midwives does not meet the recommended
standard of 1 / 3000, and the number of midwives has declined over 60% since 2001. Only 31%
of all villages are reported to have a midwife living in the village. Nearly 90% of all midwives are
reported to be APN-trained, half as many have received BEONC training.

Antenatal Care Coverage


Among reported pregnancies, 82% of the women attended at least one antenatal visit (ANC1).
This drops to 71% coverage of 4 total antenatal visits (ANC4), which is below the 2007 target of
84%. The difference between ANC4 and ANC1 is
also significant, suggesting that over 6000 women
Antenatal Care Coverage 2005
who have accessed antenatal care once but do not
obtain the minimum standard of 4 antenatal visits.
ANC1 & 4
These women are either not adhering to the recom71%
mended antenatal schedule or are accessing ANC
no ANC
ANC1 only
18%
11%
too late to reach 4 visits. Quality of care, community
awareness, and logistical accessibility factors likely

Provincial Reproductive Health & MPS Profile of Indonesia

SOUTHEAST SULAWESI
account for these missed opportunities. Nearly 10,000 pregnant women never accessed any
antenatal care in Southeast Sulawesi.

coverage by most districts, however, one district (Wakatobi) did report lower rates of SBA (49%)
compared to the provincial average.

The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in Southeast Sulawesi. Almost 90% of women report having an abdominal
examination; 82% report having their blood pressure measured and 72% received iron tablets.
However, only 66% report having their weight measured, 26% report being informed of signs of
pregnancy complications and 21% gave a blood sample. These data show that critical components of antenatal care are often not provided, and the overall quality of antenatal care should be
examined more closely.

There is an inconsistent trend toward increasing coverage of antenatal care (ANC4) from 52% to
70%. There was no change in SBA coverage since 2001.

There is minimal variation in reported antenatal coverage by most districts, however, two districts
reported low rates of ANC1 and ANC4 compared to the provincial average. (Konsel: 69% and
59%; Kota Bau Bau: 59% and 52%)

The IDHS estimates that only 22% of all births are officially registered in Southeast Sulawesi, far
lower than the national average. About 76% of all reported newborn attend the first and second
neonatal visits (KN1, KN2) and 1% attends KN1 only. The IDHS estimates similar rates of postpartum/neonatal care attendance and similar rates of missing care altogether (23%).
Postpartum / Neonatal Care

Skilled Birth Attendance

Birth Registration and Postnatal Care (IDHS, 2002/3)


80.0%

Coverage 2005

60.0%
40.0%

KN1 &
KN2, 76%

Place of Delivery (IDHS, 2002/3)

Skilled Birth Attendant Coverage


2005

no
postnatal /
neonatal
care, 22%

100.0%
80.0%

no SBA
30%

Postpartum (Neonatal) Care Coverage

60.0%

20.0%
0.0%

KN1 only,
1%

birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

Southeast Sulaw esi

21.6%

69.5%

4.5%

2.4%

23.4%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

40.0%
20.0%

SBA
70%

Only 70% of all reported deliveries are


attended by a skilled health professional
(SBA=skilled birth attendant). This leaves
over 15,000 women delivering without any
skilled birth attendant. The national target
for skilled birth attendance is 82% by 2007
and 90% by 2010; Southeast Sulawesi is
below this expectation.
Women in Southeast Sulawesi are less
likely to deliver with a doctor or nurse/midwife compared to the Indonesian average.
Only 4% are attended by a doctor and 39%
by a midwife or nurse. More than 56% are
delivered by a TBA, relative or other person. Only 6% deliver at a health facility,
while 93% deliver at home.
There is minimal variation in reported SBA

0.0%

public health private health


facility
facility

home

other /
missing

Southeast Sulaw esi

3.6%

2.5%

93.0%

0.8%

Indonesia

9.2%

30.5%

59.0%

1.2%

Risk Detection and Management of Complications

Assistance During Delivery (IDHS, 2002/3)


60.0%
40.0%
20.0%
0.0%

Ob/Gyn or midw ife or


GP
nurse

TBA

relative or
other

nobody

Southeast Sulaw esi

3.5%

38.5%

54.5%

1.8%

0.9%

Indonesia

11.0%

55.3%

31.5%

1.3%

1.1%

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005
100.0%
50.0%
0.0%
k4

2001

2002

2003

2004

2005

53.3% 66.6% 81.6% 71.3% 70.2%

SBA 69.9% 72.4% 75.4% 68.1% 69.6%

In Indonesia one of the indicator measuring


progress toward making pregnancy safer
is the rate of pregnant women detected as
at risk by the community, including cadres, TBAs or other lay persons (i.e. nonhealth professionals). Indonesia adopted
that 20% of all pregnant women will need
medical attention during pregnancy or delivery, or almost 11,000 pregnant women in
Southeast Sulawesi annually (20% of all
pregnant women reported).

Pregnancy Risk Detection


and Management of Complications
80.0%
60.0%
40.0%
20.0%
0.0%

detected by
community

detected by
health provider

maternal
complications

denominator=20% reported
pregnancies

46.0%

60.1%

15.9%

denominator=all pregnant
w omen

9.2%

12.0%

3.2%

Overall, 46% of this total number of women was detected as being at risk by community members, and 60% were detected by a health provider (denominator adjusted, applicable to reporting
districts only).
Only 16% of maternal complications were reported to have been managed, and less than 3% of
expected neonatal complications (25% of live births) were reported as managed. These calculations were based on only four reporting districts. The national target for obstetric or neonatal
complications management is 60% by 2007 and 80% by 2010.

Provincial Reproductive Health & MPS Profile of Indonesia

175

SOUTHEAST SULAWESI
Maternal and Neonatal Deaths
There were 62 maternal deaths reported in
Southeast Sulawesi in 2005, 1.5% of all reported maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 129
/ 100,000 live births. This is smaller than national estimates (MMR=230, range 58 to 440,
WHO/UNICEF/UNFPA, 2000 or MMR=307,
IDHS, 2002/3) and suggests under-reporting.

Hospital Management of Maternal and Neonatal Complications


Causes of Maternal Deaths, 2005
bleeding
54%

other /
unknown
8%

eclampsia
27%
infection
11%

The predominant cause of maternal death


Maternal Mortality Ratio 2001-05
in Southeast Sulawesi is bleeding, though
(deaths / 100,000 reported newborn)
(not reported in 2002)
eclampsia plays a significant role. Key
165
180
interventions to reduce risk of hemor154
160
rhage should be emphasized (iron defi129
140
120
98
ciency anemia control, trained midwives,
100
80
appropriate use of oxytocics in active
60
rd
management of 3 stage as per national
40
20
policy, access to safe blood transfusion/
0
2001
2002
2003
2004
2005
fluid replacement). Women with signs or
symptoms of hypertensive disorders of
pregnancy should be treated properly and
actively referred to specialist care at a hospital, since early delivery by c-section is the most effective measure to prevent progression to eclampsia and death.
It should be noted that only 8% of all maternal deaths are not attributed to any immediate cause
of death, which is among the lowest rates in the country. It is valuable for a province to correctly
diagnose and record causes of maternal deaths in order to more closely track progress toward
effective management of obstetric complication and identify potential interventions to reduce maternal mortality.
The number of reported stillbirths and neonatal deaths indicates under-reporting. Based on reported data, Southeast Sulawesi has a neonatal mortality rate of only 8.7 compared to a national
estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the
Southeast Sulawesi data on neonatal mortality are accurate enough to utilize as an outcome indicator. According to IDHS 2002/2003, the neonatal mortality rate is 36/1000 births. The highest
neonatal mortality rate. This province need big effort to achive the 2009 target, 15/1000 births.
The ratio of early to late neonatal deaths is consistent with the expected ratio. About 83% of
neonatal deaths are reported to have occurred before 7 days, suggesting the importance of improving quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g.
resuscitation, infection prevention, early detection and treatment of sepsis, and management of
low birth weight newborn).

Reported data from hospitals in Southeast Sulawesi indicate that over 2% of all deliveries occur
in hospital. About 50% of these deliveries are classified as complicated.
The case fatality rate for complications among hospital deliveries is moderate at 0.9% (WHO>1%),
but only 11% of all maternal deaths occurred in hospital.
Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
Number

% of Hospital Cases

% Coverage
(reported pregnancies) 1

OB/GYN cases treated at hospital (includes normal deliveries)

1093

--

2.1% of all pregnancies

Complicated OB/GYN cases treated at


hospital 2

550

50.3

--

0.91

11% of reported maternal


deaths (49 in 2004) occurred
in hospital

Hospital admissions due to abortion

276

25.3

--

Caesarean sections

176

16.1

0.3% of all deliveries

HOSPITAL CASES

Case fatality rate 3

Denominators from 2004 data were pregnancies: 53,289; deliveries: 50,867.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Over 25% of all hospital admissions are due


to abortion, suggesting a high rate of unsafe
Obstetric Complications at Hospital 2004
abortion practices in Southeast Sulawesi. Only
16% of all deliveries in hospital are by caesarabortion
other /
50%
unknown
ean section which is consistent with the rate
41%
of complicated deliveries reported among all
hospital deliveries. The c-section rate over all
bleeding
deliveries in the province is less than 0.3% and
infection
4%
eclampsia
0.2%
5%
suggests that there are some women delivering outside of hospitals who would have had
better outcomes if delivered by c-section. Internationally, from 5-15% of women are expected to
require delivery by c-section for optimal maternal/neonatal outcome.

The reported stillbirth rate is 7.4 / 1000 estimated deliveries in Southeast Sulawesi compared to
the national estimate of 17.

176

Provincial Reproductive Health & MPS Profile of Indonesia

SOUTHEAST SULAWESI
Recommendations

BEONC UNMET NEED ACCORDING TO STANDARDS

Coverage of health personnel and service inputs

District

1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold) to investigate apparent deficiencies (real or poor data reporting?), reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received BEONC training. Ensure that every
puskesmas has at least one trained ANC midwife.
4. Investigate the reason behind low ANC1 coverage. Why do so many women never access
antenatal care? Investigate the reasons behind the difference between ANC4 and ANC1
rates of attendance. Who are these women entering the system but not being retained?
Why do they drop out?
5. Increase the number of women who deliver with a skilled birth attendant and improve access to BEONC and CEONC facilities in case of delivery obstetric or complication.
6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
8. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

1
2
3
4
5
6
7
8
9
10

Total pop- # BEONC


ulation
in 2005

Konawe
26,211
Konsel
229,574
Kolaka
328,419
Kolaka Utara
94,417
Buton
466,915
Wakatobi
93,419
Bombana
105,927
Muna
294,484
Kota Bau - Bau
116,685
Kota Kendari
220,732
TOTAL 1,976,783

5
1
4
0
0
0
0
0
0
0
10

Total Unmet
WHO recommend- Unmet
Pop. /
Need (MOH:
ed coverage
need
BEONC
4 / district)
(1 / 125,000)
(WHO)
0
5,242
1
0
3
229,574
2
1
0
82,105
3
0
4
-1
1
4
-4
4
4
-1
1
4
-1
1
4
-2
2
4
-1
1
4
-2
2
31
197,678
17
13

COVERAGE OF MIDWIFE PERSONNEL


Total reported
District
deliveries
1 Konawe
6,758
2 Konsel
6,061
3 Kolaka
6,525
4 Kolaka Utara
2,829
5 Buton
7,476
6 Wakatobi
1,747
7 Bombana
2,301
8 Muna
7,970
9 Kota Bau - Bau
2,949
10 Kota Kendari
5,328
TOTAL

49,944

KEY INDICATORS AND NATIONAL TARGETS

Total APN midwives


164
96
85
18
94
10
12
0
30
12
521
(1 / 96 deliveries)

Southeast Sulawesi

70

84

95

70

70

82

90

83

78

83

90

11.8

46.0

Obstetric complications managed

Not reported

15.9

60

80

11. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.

Neonatal complications managed

Not reported

2.6

60

80

Caesarian section rate (% of hospital deliveries)

11.2

16.1 *

Caesarian section rate (% of reported deliveries)

0.6

0.3 *

12. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Hospital OB/GYN cases as % of all pregnancies

4.9

2.1 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

154

129

10. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.

ANC1 (K1)

94

82

ANC4 (K4)

53

SBA deliveries
Postpartum / Neonatal visit (KN1)

National Target
2010

9. Review systems for documenting and counting total deliveries, and live births to ensure
these important denominators are reported accurately.

2005 *

80
34
29
6
88
0
0
0
0
0
211
1 / 1308 deliveries)

2007

Data quality and reporting

2001

Total BEONC midwives

Risk detection of pregnant women by community

* c-sections and hospital data from 2004.

Provincial Reproductive Health & MPS Profile of Indonesia

177

SOUTHEAST SULAWESI

178

Provincial Reproductive Health & MPS Profile of Indonesia

GORONTALO

he total population of Gorontalo is small at only


950,000, accounting for only 0.4% of the total
population in Indonesia, and only 6% of the population in Sulawesi. Gorontalo is divided into 5
districts (4 kabupaten + 1 Kota [cities]) with a total of 476
villages. The capital is Gorontalo city.
Gorontalo was declared a separate province from North
Sulawesi in 2000, but the first health information system
data report submitted separately for Gorontalo was in 2003.
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002)

Annual growth rate (2000-2005) 2


Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

GEOGRAPHY
Total land area (km2)
Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)

12,165
5
4
1
47
476

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

Gorontalo

National

950,268
31
30
95
71
Male: 62
Female: 66
0.91
222,740 3
2.8
20.9
16.2
48.2
11.0

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

From provincial health data reports.


2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

Gorontalo has a much lower urban population (31%)


and much higher poor population (30%) compared
to the national average. Adult female literacy is also
high, however, at 95%.
The total fertility rate (2.8) is similar to the national

Contraceptive Methods Used


(IDHS 2002/3)

injection,
30%

traditional
methods, 8%

average, and crude birth rate (20.9) is slightly lower. The modern contraceptive prevalence rate is
lower (48%) and the percentage of young women who have begun childbearing is higher (16.2%).
Among all contraceptive users, most women choose oral contraceptives (33%) or injection (30%).
Other common methods include implants (17%), IUD (11%), or traditional methods (8%).

Health Facilities
Gorontalo reports 8 hospitals; 6 public and 2 private. Only 3 Ob/Gyn staff and 4 pediatricians are
reported to work in public hospitals. Both private hospitals appear to have both types of specialists.
Only 1 (public) hospital is reported as a certified provider of Comprehensive Emergency Obstetric
and Neonatal Care (CEONC). This leaves four districts with no CEONC coverage: Kab Gorontalo, Kab Boalemo, Kab Pohuwato, and Kab Bone Bolango.
2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

Hospitals with CEONC 1

In-hospital OBGYN
In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in
Puskesmas
Puskesmas with bed

3
4

Puskesmas BEONC

pill, 33%

IUD, 11%
implant, 17%
permanent,
1%

1 CEONC hospital / district

Not reported (WHO minimum standard:


one / 500,000 pop.)
2
-3
--

--

<1 / district
<1 / 500,000 pop.
1 / 4886 pregnant women
1 / 3173 newborn

53

One PHC / 30,000 pop.

1 / 17,930 pop.

50

--

1/ 19,005 pop.

18

-4 / district

34% of all puskesmas


0% of all puskesmas

(WHO minimum standard:


One / 125,000 pop.)

Average 0/district; none


reported in province

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.

Gorontalo reports 53 puskesmas (primary health centers) which meets the recommended stan-

Provincial Reproductive Health & MPS Profile of Indonesia

179

GORONTALO
dard, with 50 puskesmas-based general practitioners. One-third (34%) of puskesmas are reported to have beds for in-patient care.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


No puskesmas were reported to have received training and certification in Basic Emergency
Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO) recommended standard for BEONC facilities is 1 for every 125,000 people. Indonesia has adopted
this indicator, but translated it to mean at least four BEONC facilities for each district. For every
district to have 4 BEONC, Gorontalo should have 20 BEONC facilities. However, according to the
population size of Gorontalo, the total recommended number of BEONC facilities is only 8.
One immediate step would be to review the actual number of BEONC puskesmas in the province (are there really none?), then identify districts with more than 125,000 population for each
BEONC as priority districts for additional training (Kab Gorontalo has over 400,000 residents).
The first goal should be to reach at least 8 well-distributed BEONC facilities, and then to increase that number toward 20, with special emphasis on the four districts with limited access to
the CEONC center. The cost per puskesmas team (3 persons) to be trained in BEONC is IDR
9.3 million (3.1 per person).

Health Personnel

Not reported
Not reported

3
4

---

37

74

100%

39

16

59%

403

390

3%

188

171

9%

205
0
0
888
263
403

194
4
15
939
240
206

5%
-- 18%
%9
%49

1 / 12,841 population

1 / 2437 population
36% of villages have
village midwife
1 / 4898 population
1% midwives
1 / 63,351 population
26% of all TBA
22% of all TBA

Gorontalo reports having one Ob/Gyn for every 300,000 population and one pediatrician for every
230,000 population. Coverage of GPs meets the recommended standard (despite lack of reporting from four districts). Coverage of total midwives also meets the standard of 1/3000 population.
However, just over one-third (36%) of all villages are reported to have a midwife living in the vil-

180

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in Gorontalo of 20.9 (BPS, 2000), the reported pregnancies are about
11% higher than the estimated pregnancies, and reported deliveries are also about 11% higher
than estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries
is valid and consistent with the country overall, suggesting that the reported events are reasonably accurate. Likely explanations for this higher number of reported pregnancies and deliveries
compared to the expected number may be that the crude birth rate in Gorontalo is higher than
estimated or the population is higher than reported.
DENOMINATORS FOR
KEY INDICATORS
Reported pregnancies
Reported deliveries
Reported newborn

Number

24,428
23,251
22,208

2.57% of total population


95.2% of reported pregnancies
95.5% of reported deliveries

Ratio of reported /
estimated 1
110.8
111.5
--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

HEALTH PERSONNEL
%
2005
Coverage
2003
(minimum standard)
Change
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in BEONC
Total TBA
Trained TBA
TBA with kit

lage and village midwife coverage has decreased slightly since 2001. Only 4 midwives (1%) are
reported to be APN-trained, and 15 (4%) have received LSS training.

Antenatal Care Coverage


Among reported pregnancies, 91% of the women
attended at least one antenatal visit (ANC1). This
Antenatal Care Coverage 2005
drops to 79% coverage of 4 total antenatal visits
(ANC4), which is below the 2007 target of 84%. AlANC1 & 4
79%
`
though coverage of ANC1 care is relatively good,
the difference between ANC4 and ANC1 is large
ANC1 only
no ANC
12%
with nearly 3000 women (9%) who have accessed
9%
antenatal care once but do not obtain the minimum
standard of 4 antenatal visits. These women are either not adhering to the recommended antenatal schedule or are accessing ANC too late to reach
4 visits. Quality of care, community awareness, and logistical accessibility factors likely account
for these missed opportunities. Over 2000 pregnant women never accessed any antenatal care
in Gorontalo.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in Gorontalo. Over 80% of women report having an abdominal examination;
more than 83% report having their weight and blood pressure measured. Nearly 78% received

Provincial Reproductive Health & MPS Profile of Indonesia

GORONTALO
iron tablets, but only 30% report being informed of signs of pregnancy complications and 32%
gave a blood sample. These data show that critical components of antenatal care are often not
provided, and the overall quality of antenatal care should be examined more closely.

There is minimal variation in reported SBA


coverage by most districts.

Gorontalo submitted separate health data


reports starting in 2003. Two districts from
North Sulawesi (Kab Gorontalo and Kota
Gorontalo) were included in the trend analysis for 2001. No data from North Sulawesi
was reported for 2002. The trend is difficult
to interpret. The rates for ANC4 and SBA
coverage were similar in 2001 to reports
of 2005. The first year of Gorontalos independent data reporting in 2003 appears
to have unusually high rates of ANC4 and
SBA coverage.

no
postnatal /
neonatal
care, 17%

Skilled Birth Attendant Coverage


2005
no SBA
29%

20.0%
0.0%

KN1 only,
5%

birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

Gorontalo

27.8%

73.7%

2.7%

5.6%

17.4%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

newborn attend the first and second neonatal visits (KN1, KN2) and 5% attend KN1 only. The
IDHS estimates similar rates of postpartum/neonatal care attendance and rates of missing care
altogether (17%).

SBA
71%

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring
progress toward making pregnancy safer
is the rate of pregnant women detected as
at risk by the community, including cadres, TBAs or other lay persons (i.e. nonhealth professionals). Indonesia adopted
that 20% of all pregnant women will need
medical attention during pregnancy or delivery, or nearly 5000 pregnant women in
Gorontalo annually (20% of all pregnant
women reported).

Place of Delivery (IDHS, 2002/3)


100.0%
80.0%
60.0%
40.0%
20.0%
0.0%

public health private health


facility
facility

home

other /
missing

Gorontalo

11.7%

3.2%

83.7%

1.4%

Indonesia

9.2%

30.5%

59.0%

1.2%

Assistance During Delivery (IDHS, 2002/3)


60.0%
40.0%
20.0%
0.0%

Ob/Gyn or
GP

midw ife or
nurse

TBA

relative or
other

nobody

Gorontalo

5.8%

43.0%

50.6%

0.4%

0.0%

Indonesia

11.0%

55.3%

31.5%

1.3%

1.1%

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005
(Gorontalo reported as separate

Pregnancy Risk Detection


and Management of Complications
80.0%
60.0%
40.0%
20.0%
0.0%

detected by
community

detected by
health provider

maternal
complications

denominator=20% reported
pregnancies

10.7%

73.9%

16.3%

denominator=all pregnant
w omen

2.1%

14.8%

3.3%

Overall, only 11% of this total number of women was detected as being at risk by community
members, though 74% were detected by a health provider (denominator adjusted, applicable to
reporting districts only). The community rate of risk detection is unreliable, however, because
only 3 districts reported this indicator.
Only 16% of maternal complications were reported to have been managed, and 0.2% of expected
neonatal complications (25% of live births) were reported as managed. The national target for
obstetric or neonatal complications management is 60% by 2007 and 80% by 2010.

district from 2003; 2002 data not reported)


100.0%

0.0%

Maternal and Neonatal Deaths


2001 2002 2003 2004 2005
77.4

83.4 76.5 79.3

SBA 69.5

95.4 68.1 71.2

k4

Postpartum (Neonatal) Care


Coverage

40.0%

KN1 &
KN2, 78%

Skilled Birth Attendance

Women in Gorontalo are less likely to deliver with a doctor or nurse/midwife compared to the Indonesian average. Only 6%
are attended by a doctor and only 43% by a
midwife or nurse. More than half (51%) are
delivered by a TBA, relative or other person.
Similarly, only 15% deliver at a health facility
(mostly public), while 84% deliver at home.

80.0%
60.0%

There is minimal variation in reported antenatal coverage by most districts.

Only 71% of all reported deliveries are attended by a


skilled health professional (SBA=skilled birth attendant). This leaves more than 6600 women delivering without any skilled birth attendant. The national
target for skilled birth attendance is 82% by 2007 and
90% by 2010; Gorontalo is behind this expectation.

Birth Registration and Postnatal Care (IDHS, 2002/3)

Postpartum / Neonatal Care


Coverage 2005

The IDHS estimates that only 28% of all births are officially registered in Gorontalo, about half as
low as the national average and among the lowest rates in the country. About 78% of all reported

There were 45 maternal deaths reported in Gorontalo in 2005, over 1% of all reported maternal
deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 203 / 100,000 live births.
This is within range of national estimates (MMR=230, range 58 to 440, WHO/UNICEF/UNFPA,
2000 or MMR=307, IDHS, 2002/3) and suggests that Gorontalo may have among the highest
MMRs in the country, since almost every province appears to significantly under-reported maternal deaths.

Provincial Reproductive Health & MPS Profile of Indonesia

181

GORONTALO
The predominant cause of maternal death in
Gorontalo is bleeding, though eclampsia plays a
significant role. Key interventions to reduce risk of
hemorrhage should be emphasized (iron deficiency
anemia control, trained midwives, appropriate use
of oxytocics in active management of 3rd stage as
per national policy, access to safe blood
transfusion/fluid replacement). Women
with signs or symptoms of hypertensive
disorders of pregnancy should be treated
350
properly and actively referred to special300
ist care at a hospital, since early delivery 250
by c-section is the most effective measure 200
to prevent progression to eclampsia and 150
100
death.

Causes of Maternal Deaths, 2005

other /
unknown
39%

bleeding
45%
eclampsia
16%

(2002 data not repoted)

309

178

203

50
0
It should be noted that 39% of all maternal
2001
2002
2003
2004
2005
deaths are not attributed to any immediate
cause of death. More importance should
be attached to correctly diagnosing and recording causes of maternal deaths in order to more
closely track progress toward effective management of obstetric complication and identify potential interventions to reduce maternal mortality.

The number of reported stillbirths and neonatal deaths indicates under-reporting. Based on reported data, Gorontalo has a neonatal mortality rate of only 3.6 compared to a national estimate
of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the Gorontalo
data on neonatal mortality are accurate enough to utilize as an outcome indicator. According to
IDHS 2002/2003, the neonatal mortality rate is 24/1000 births. This province need some effort to
achive the 2009 target, 15/1000 births.
The ratio of early to late neonatal deaths is consistent with the expected ratio. About 77% of
neonatal deaths are reported to have occurred before 7 days, suggesting the importance of improving quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g.
resuscitation, infection prevention, early detection and treatment of sepsis, and management of
low birth weight newborn).
The reported stillbirth rate is 8.7 / 1000 estimated deliveries in Gorontalo compared to the national
estimate of 17.

Hospital Management of Maternal and Neonatal Complications


Gorontalo hospital data was not reported separately from North Sulawesi in the most recently
available database from 2004. Since the total number of hospitals in North Sulawesi was not
reported in many districts, it is difficult to estimate the proportion of Gorontalo hospitals compared
to North Sulawesi hospitals, however, it is likely to be less than one-third. Therefore, the validity
of relying on North Sulawesi hospital data to describe Gorontalo province is poor.

182

other /
unknown 41%

abortion
28%
eclampsia
9%

The case fatality rate for complications among hospital deliveries is low at 0.4%, but only 15% of all
reported maternal deaths occurred in the hospital.

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)

219

Obstetric Complications at Hospital 2004


(North Sulawesi)

Reported data from hospitals in North Sulawesi/


Gorontalo indicate that more than 13% of all deliveries occur in hospital. About 41% of these deliveries
are classified as complicated.

(there were no reported deaths due to infection)

bleeding
22%

Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
Over 11% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion
practices in North Sulawesi/Gorontalo. About 23% of all deliveries in hospital are by caesarean
section which is consistent with the rate of complicated deliveries reported among all hospital
deliveries. The c-section rate over all deliveries in the province is 3.2% which is higher than most
provinces, but still suggests that there are women delivering outside of hospitals who would have
had better outcomes if delivered by c-section. Internationally, from 5-15% of women are expected
to require delivery by c-section for optimal maternal/neonatal outcome.
HOSPITAL CASES
OB/GYN cases treated at hospital (includes
normal deliveries)
Complicated OB/GYN cases treated at hospital 2
Case fatality rate 3
Hospital admissions due to abortion
Caesarean sections

Number

% of Hospi% Coverage
tal Cases (reported pregnancies) 1

6515

--

13.2% of all pregnancies

2657

40.8

--

11

0.41

737
1478

11.3
22.7

14.7% of reported maternal


deaths (75 in 2004) occurred
in hospital
-3.2% of all deliveries

Denominators from 2004 data were pregnancies: 49,516; deliveries: 45,611.


Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1
2

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.

Provincial Reproductive Health & MPS Profile of Indonesia

GORONTALO
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.

BEONC UNMET NEED ACCORDING TO STANDARDS

Total Unmet
WHO recomUnmet
Total
# BEONC
Pop. /
Need (MOH:
mended coverage need
population in 2005
BEONC
4 / district)
(1 / 125,000)
(WHO)
Kota Gorontalo
142,432
0
(4)
-1
-Kab. Gorontalo
420,950
0
(4)
-3
-Kab. Boalemo
109,434
0
(4)
-1
-Kab. Pohuwato
108,544
0
(4)
-1
-Kab. Bone Bolango
168,908
0
(4)
-1
-TOTAL
950,268
0
Up to 20
-8
--

District
1
2
3
4
5

3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.
4. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they
drop out?

COVERAGE OF MIDWIFE PERSONNEL


Total reported
District
deliveries

5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.

1
2
3
4
5

6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.

Kota Gorontalo
Kab. Gorontalo
Kab. Boalemo
Kab. Pohuwato
Kab. Bone Bolango
TOTAL

3,703
10,723
2,771
2,737
3,317
23,251

8. Improve classification of maternal deaths by cause to reduce the proportion reported as


unknown.
9. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


10. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
11. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
12. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.
13. Ensure that hospital data are reported separately for Gorontalo.

KEY INDICATORS AND NATIONAL TARGETS


ANC1 (K1)
ANC4 (K4)
SBA deliveries
Postpartum / Neonatal visit (KN1)
Risk detection of pregnant women by community
Obstetric complications managed
Neonatal complications managed
Caesarian section rate (% of hospital deliveries)
Caesarian section rate (% of reported deliveries)
Hospital OB/GYN cases as % of all pregnancies
Maternal Mortality Ratio
(maternal deaths / 100,000 reported live births)

Total APN midwives

Total BEONC midwives

0
1
3
0
0
4
(1 / 5813 deliveries)

3
3
3
3
3
15
1 / 1550 deliveries)

Gorontalo

National Target

2003

2005 *

100
83
95
70
8.7
Not reported
Not reported
15.7 1
3.3 1
19.0 1

91
79
71
83
10.7
16.3
0.2
22.7 2 *
3.2 2 *
13.2 2 *

309

203

2007

2010

84
82
83

95
90
90

60
60

80
80

Not a separate province in 2001; these are data from North Sulawesi which included Gorontalo districts.
Hospital data not reported separately for Gorontalo in 2004 database, so these are from North Sulawesi.
* c-sections and hospital data from 2004.
1
2

Provincial Reproductive Health & MPS Profile of Indonesia

183

GORONTALO

184

Provincial Reproductive Health & MPS Profile of Indonesia

WEST
SULAWESI

he total population of West Sulawesi is small at


fewer than 974,000, accounting for only 0.4% of
the total population in Indonesia, and only 6% of
the population in Sulawesi. West Sulawesi is divided into 5 districts (5 kabupaten + 0 Kota [cities]) with a
total of 491 villages. The capital is Mamuju.

GEOGRAPHY

Total land area (km )


Number of districts
Kabupaten (regencies)
Kota (municipalities)
Kecamatan (sub-districts)
Kelurahan/Desa (villages)
2

16,787
5
5
0
51
491

Source: Beberapa Indikator Penting Sosial-

West Sulawesi was declared a separate province from


Ekonomi Indonesia, Edisi Juli 2006, BPS.
South Sulawesi in 2004. The first health information system data report submitted separately for West Sulawesi was in 2004; the IDHS data was collected
prior to separation of this province, and available BPS data also does not report separately for
West Sulawesi.
BPS data from South Sulawesi show a much lower urban population (32%) and similar poor
population (15%) compared to the national average. Adult female literacy is lower at 82%.
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

West Sulawesi *
973,475
32
15
82
136
Male: 67
Female: 71
1.08
228,183 3
2.6
22.9
13.6
42.4
11.8

National

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

* All statistics except for population are not reported separately by BPS or DHS for West Sulawesi. Therefore, they are from
South Sulawesi which included West Sulawesi districts until the HIS report of 2004.
1
From provincial health data reports.
2
Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000.
6
IDHS 2002/3.

The total fertility rate (2.6) and crude birth rate


(22.9) are similar to the national average. The
modern contraceptive prevalence rate is lower
(42%) and the percentage of young women who
have begun childbearing is higher (13.6%). IDHS
data show that among all contraceptive users,
most women choose injection (47%), oral contraceptives (27%) or traditional methods (14%).

Contraceptive Methods Used


(IDHS 2002/3; South Sulawesi)
injection,
47%
pill, 27%
traditional
methods,
14%

implant, 6%

permanent,
3%

IUD, 2%

Health Facilities
No data reports were submitted on health facilities in 2004 or 2005. West Sulawesi districts, part of
South Sulawesi prior to 2004, also did not report any of these indicators in 2001-2003. Therefore, total
hospitals, puskesmas or CEONC facilities is not available for this profile.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


The number of BEONC (Basic Emergency Obstetric and Neonatal Care) is not reported. The
current World Health Organization (WHO) recommended standard for BEONC facilities is 1 for
every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least
four BEONC facilities for each district. For every district to have 4 BEONC, West Sulawesi should
have 20 BEONC facilities. However, according to population size, the minimum total recommended number is only 8.
One immediate step would be to review the actual number of BEONC puskesmas in the province. The first goal should be to reach at least 8 well-distributed BEONC facilities, and then
to increase that number toward 20. The cost per puskesmas team (3 persons) to be trained in
BEONC is IDR 9.3 million (3.1 per person).

Health Personnel
Total specialists is not reported in West Sulawesi, nor is coverage of GPs. Coverage of midwives
is below the recommended standard. An additional 134 midwives would be required to meet the

Provincial Reproductive Health & MPS Profile of Indonesia

185

WEST SULAWESI
standard of 1 / 3000 population. Only 30% of all villages report having a midwife living in the village, and only 13% are reported to be APN-trained; none have received LSS training.
HEALTH PERSONNEL
2005
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs

Not reported

Pediatricians

Not reported

Primary health center general practitioners


(One GP / 30,000 pop.)

Not reported

Nurses trained in ANC

Not reported

--

Total midwives
(One / 3000 pop.)

190

1 / 5124 population

Midwives living in the village


(One / village)

148

30% of villages have village midwife

Midwives with a kit

27

1 / 36,055 population

Midwives trained in APN

24

13% midwives

Midwives trained in BEONC

--

Total TBA

Not reported

Trained TBA

Not reported

--

TBA with kit

Not reported

--

Ratio of reported
/ estimated 1

Reported pregnancies

25,361

2.61% of total population

102.5

Reported deliveries

24,309

95.9% of reported pregnancies

103.9

Reported newborn

22,569

92.8% of reported deliveries

--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.


A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.


Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.


Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.
Assuming a crude birth rate in West Sulawesi of 22.9 (BPS, 2000), the reported pregnancies are
about 2% higher than the estimated pregnancies, and reported deliveries are about 4% higher
than estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries
is valid and consistent with the country overall, suggesting that the reported events are reasonably accurate. Likely explanations for this higher number of reported pregnancies and deliveries
compared to the expected number may be that the crude birth rate in West Sulawesi is higher
than estimated or the population is higher than reported.

186

Among reported pregnancies, only 62% of the womAntenatal Care Coverage 2005
en attended at least one antenatal visit (ANC1). This
drops to 56% coverage of 4 total antenatal visits
ANC1 & 4
56%
(ANC4), which is far below the 2007 target of 84%.
no ANC
Coverage of ANC1 care is very poor. Up to 1500
ANC1 only
38%
6%
women who have accessed antenatal care once
do not obtain the minimum standard of 4 antenatal
visits. These women are either not adhering to the
recommended antenatal schedule or are accessing
ANC too late to reach 4 visits. Quality of care, community awareness, and logistical accessibility
factors likely account for these missed opportunities. Nearly 10,000 pregnant women never accessed any antenatal care in West Sulawesi.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in South Sulawesi, which contained West Sulawesi districts at that time.
Over 96% of women report having an abdominal examination; more than 91% report having their
weight and blood pressure measured. Nearly 73% received iron tablets, but only 15% report
being informed of signs of pregnancy complications and 59% gave a blood sample. These data
show that critical components of antenatal care are often not provided, and the overall quality of
antenatal care should be examined more closely.

Primary Health Care Indicators


DENOMINATORS FOR KEY
Number
INDICATORS

Antenatal Care Coverage

There is minimal variation in reported antenatal coverage by most districts, however, one district
(Mamuju Utara) had lower rates of ANC1 and ANC4 compared to the provincial average (26%
and 23% respectively).

Skilled Birth Attendance


Only 52% of all reported deliveries are attended by a skilled health professional (SBA=skilled birth
attendant). This leaves almost 12,000 women delivering without any skilled birth attendant. The
national target for skilled birth attendance is 82% by 2007 and 90% by 2010; West Sulawesi is far
behind this expectation.
Women in South Sulawesi (including West Sulawesi at the time) are less likely to deliver with a
doctor compared to the Indonesian average. Only 7% are attended by a doctor and 56% by a
midwife or nurse. More than one-third (37%) are delivered by a TBA, relative or other person.
Skilled Birth Attendant Coverage
2005
no SBA
48%

Provincial Reproductive Health & MPS Profile of Indonesia

SBA
52%

Place of Delivery (IDHS, 2002/3)


(South Sulawesi)
80.0%
60.0%
40.0%
20.0%
0.0%

public health
private
facility
health facility

home

other /
missing

South Sulaw esi

20.3%

15.1%

63.9%

0.6%

Indonesia

9.2%

30.5%

59.0%

1.2%

WEST SULAWESI
One-third (35%) deliver at a health facility,
while 64% deliver at home.

Assistance During Delivery (IDHS, 2002/3)


(South Sulawesi)
60.0%

There is minimal variation in reported SBA


coverage by most districts, however, the
same district doing poorly in antenatal
care, Mamuju Utara, reported only 17%
SBA coverage
Antenatal coverage since 2001 show inconsistent trends suggestive of a slight
decrease in antenatal coverage, and no
change in SBA coverage (West Sulawesi
districts were extracted from South Sulawesi data reports prior to 2004).

20.0%
0.0%

Ob/Gyn or

midw ife or

TBA

relative or

nobody

South Sulaw esi

6.7%

55.5%

31.2%

5.7%

0.5%

Indonesia

11.0%

55.3%

31.5%

1.3%

1.1%

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005

40.0%

Only 1% of maternal complications were


reported to have been managed, and 1%
of expected neonatal complications (25%
of live births) were reported as managed.
The national target for obstetric or neonatal complications management is 60% by
2007 and 80% by 2010.

20.0%
0.0%

detected by
community

detected by
health provider

maternal
complications

denominator=20% reported
pregnancies

26.9%

54.0%

1.1%

denominator=all pregnant
w omen

5.4%

10.8%

0.2%

Maternal and Neonatal Deaths

50.0%
0.0%

2001

2002

2003

2004

2005

59.1% 60.5% 56.5% 46.3% 56.3%

Postpartum (Neonatal) Care Coverage


The IDHS estimates that only 41% of all births are officially registered in South Sulawesi/West
Sulawesi, lower than the national average. About 63% of all reported newborn attend the first
neonatal visit (KN1); KN2 was not reported. These data are not consistent with rates reported
for South Sulawesi from the IDHS estimates, and suggest that health indicators are worse in the
districts that formed West Sulawesi in 2004.
Birth Registration and Postnatal Care (IDHS, 2002/3)
(South Sulawesi)
80.0%
60.0%
40.0%

no
postnatal /
neonatal
care, 37%

60.0%

100.0%

SBA 49.7% 45.5% 50.9% 42.1% 51.6%

KN1, 63%

Pregnancy Risk Detection


and Management of Complications

40.0%

k4

Postpartum / Neonatal Care


Coverage 2005 (KN2 not reported)

members, though 54% were detected by


a health provider (denominator adjusted,
applicable to reporting districts only).

20.0%
0.0%

birth
postnatal postnatal postnatal
no
registratio 0-2 days 3-6 days 7-41 days postnatal

South Sulaw esi

40.8%

76.1%

3.2%

1.4%

19.3%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate
of pregnant women detected as at risk by the community, including cadres, TBAs or other lay
persons (i.e. non-health professionals). Indonesia adopted that 20% of all pregnant women will
need medical attention during pregnancy or delivery, or more than 5000 pregnant women in West
Sulawesi annually (20% of all pregnant women reported).
Overall, only 27% of this total number of women was detected as being at risk by community

There were 29 maternal deaths reported


in West Sulawesi in 2005, less than 1%
of all reported maternal deaths in Indonesia. The estimated maternal mortality
ratio (MMR) is 128 / 100,000 live births.
This is far smaller than national estimates
(MMR=230, range 58 to 440, WHO/UNICEF/UNFPA, 2000 or MMR=307, IDHS,
2002/3) and suggests under-reporting.

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)
(not reported in 2004)

145

160
140
120
100

128

100

80

56

60
40
20
0
2001

2002

2003

2004

2005

The predominant cause of maternal death


in West Sulawesi was not reported, but in
almost all provinces of Indonesia, it is bleeding followed by eclampsia. Key interventions to reduce risk of hemorrhage should be emphasized (iron deficiency anemia control, trained midwives,
appropriate use of oxytocics in active management of 3rd stage as per national policy, access
to safe blood transfusion/fluid replacement). Women with signs or symptoms of hypertensive
disorders of pregnancy should be treated properly and actively referred to specialist care at a
hospital, since early delivery by c-section is the most effective measure to prevent progression to
eclampsia and death.
It should be noted that a significant proportion of all maternal deaths are usually not attributed
to any immediate cause of death. More importance should be attached to correctly diagnosing
and recording causes of maternal deaths in order to more closely track progress toward effective management of obstetric complication and identify potential interventions to reduce maternal
mortality.
The number of reported stillbirths and neonatal deaths indicates under-reporting. Based on reported data, West Sulawesi has a neonatal mortality rate of only 5.2 compared to a national estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the West
Sulawesi data on neonatal mortality are accurate enough to utilize as an outcome indicator.
The ratio of early to late neonatal deaths is inconsistent with the expected ratio at only 53% and

Provincial Reproductive Health & MPS Profile of Indonesia

187

WEST SULAWESI
suggest under-reporting of early neonatal deaths. In Indonesia, about of all neonatal deaths
occur before 7 days, suggesting the importance of improving quality and access to pregnancy
care, safer delivery and emergency neonatal care (e.g. resuscitation, infection prevention, early
detection and treatment of sepsis, and management of low birth weight newborn).
The reported stillbirth rate is 4.9 / 1000 estimated deliveries in West Sulawesi compared to the
national estimate of 17.

Hospital Management of Maternal and Neonatal Complications


West Sulawesi hospital data was not reported
separately from South Sulawesi in the most recently available database from 2004. Below is the
description of data from South Sulawesi, however,
since the population of West Sulawesi is very small
compared to South Sulawesi and health indicators
are very different, these data are not likely to be a
valid description of West Sulawesi.

Obstetric Complications at Hospital 2004


(South Sulawesi)
abortion
52%
bleeding
14%

infection
2.7%

other /
unknown
26%

eclampsia
5%

be an important indicator to monitor nationally.


Over 27% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion practices in South Sulawesi. About 33% of all deliveries in hospital are by caesarean section
which is consistent with the rate of complicated deliveries reported among the few hospital deliveries. The c-section rate over all deliveries in the province is less than 1% and suggests that there
are some women delivering outside of hospitals who would have had better outcomes if delivered
by c-section. Internationally, from 5-15% of women are expected to require delivery by c-section
for optimal maternal/neonatal outcome.

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.

Reported data from hospitals in South Sulawesi indicate that just over 2% of all deliveries occur
in hospital. About 53% of these deliveries are classified as complicated.

2. Determine the number of BEONC and CEONC facilities over the province. Ensure minimum standards of distribution of BEONC and CEONC facilities across all districts, and
correlation with population size.

HOSPITAL CASES

Num- % of Hos% Coverage


ber pital Cases (reported pregnancies) 1

3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.

OB/GYN cases treated at hospital (includes normal deliveries)

4244

--

2.3% of all pregnancies

Complicated OB/GYN cases treated at hospital

2237

52.7

--

12

0.54

Maternal deaths not reported through HIS in 2004

4. Investigate the reason behind low ANC1 coverage. Why do so many women never access
antenatal care? Investigate the reasons behind the difference between ANC4 and ANC1
rates of attendance. Who are these women entering the system but not being retained?
Why do they drop out?

Hospital admissions due to abortion

1169

27.5

--

Caesarean sections

1378

32.5

0.8% of all deliveries

Case fatality rate 3

Denominators from 2004 data were pregnancies: 183,219; deliveries: 174,891.


Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.

The case fatality rate for complications among hospital deliveries is low at 0.5% (WHO>1%).
The proportion of maternal deaths occurring in hospital cannot be determined because maternal
deaths were not reported in 2004. Based on the number of death sin 2005, however, it is likely
to be below 10%.
Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would

188

6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
8. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
9. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Provincial Reproductive Health & MPS Profile of Indonesia

WEST SULAWESI
Data quality and reporting
10. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.
11. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
12. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.
13. Ensure separate reporting of West Sulawesi hospital data.
BEONC UNMET NEED ACCORDING TO STANDARDS

#
Total Unmet
Total
Pop. /
BEONC Need (MOH:
population
BEONC
in 2005 4 / district)

1
2
3
4
5

Polmas
Majene
Mamuju
Mamasa
Mamuju Utara
TOTAL

356,818
140,159
256,328
125,192
94,978
973,475

(4)
(4)
(4)
(4)
(4)
Up to 20

Not reported

District

-------

WHO
recommended
coverage
(1 / 125,000)

COVERAGE OF MIDWIFE PERSONNEL


Total reported delivDistrict
Total APN midwives
eries
1
2
3
4
5

Polmas
Majene
Mamuju
Mamasa
Mamuju Utara

TOTAL

7,708
3,466
7,308
3,187
2,640

24,309

10
7
7
0
0
24
(1 / 1013 deliveries)

Unmet
need
(WHO)
3
1
2
1
1
8

-------

KEY INDICATORS AND NATIONAL TARGETS

West Sulawesi

National Target

2001

2005

2007

2010

ANC1 (K1)

88

62

ANC4 (K4)

59

56

84

95

SBA deliveries

50

52

82

90

Postpartum / Neonatal visit (KN1)

65

63

83

90

Risk detection of pregnant women by community

Not reported

26.9

Obstetric complications managed

Not reported

1.1

60

80

Neonatal complications managed

Not reported

1.0

60

80

Caesarian section rate (% of hospital deliveries)

20.0

32.5

Caesarian section rate (% of reported deliveries)

1.1 1

0.8 2

Hospital OB/GYN cases as % of all pregnancies

5.0 1

2.3 2

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

100

128

Not a separate province in 2001; these are data from South Sulawesi which included West Sulawesi districts.
Hospital data not reported separately for West Sulawesi in 2004 database, so these are from South Sulawesi.
* c-sections and hospital data from 2004.
1
2

Total BEONC midwives


Not reported

--

Provincial Reproductive Health & MPS Profile of Indonesia

189

WEST SULAWESI

190

Provincial Reproductive Health & MPS Profile of Indonesia

WEST NUSA TENGGARA


(NTB)

he total population of West Nusa Tenggara is 4 GEOGRAPHY


million, accounting for 2% of the total population Total land area (km2)
19,709
in Indonesia, and nearly 35% of the population in Number of districts
9
7
the region (Bali, East and West Nusa Tenggara). Kabupaten (regencies)
Kota
(municipalities)
2
West Nusa Tenggara is divided into 9 districts (7 kabuKecamatan
(sub-districts)
100
paten + 2 kota [cities]) with a total of 820 villages. The
Kelurahan/Desa (villages)
820
two largest islands comprising West Nusa Tenggara are Source: Bzeberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.
Lombok and Sumbawa. The capital is Mataram on Lombok. A United Nations Development Programme (2002)
report classified West Nusa Tenggara as the least developed province in Indonesia.
West Nusa Tenggara has a lower urban population (42%) and higher poor population (23%)
compared to the national average. Adult female literacy is significantly lower than the national
rate at 71%.
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2
Adult female literacy rate (2004) 2
Population density (km sq.; 2005) 2
Life expectancy at birth (2002) 2
Annual growth rate (2000-2005)
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun
childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6
2

West Nusa Tenggara

National

4,005,360
42
23
71
216
Male: 57
Female: 61
1.67
938,860 3
2.4
27.0

220,659,431
48
17
87
116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0

12.1

10.4

52.5
16.0

56.7
8.6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population,
using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7,
5
BPS 2000
6
IDHS 2002/3
1

modern contraceptive prevalence rate is slightly


lower (53%) and the percentage of young women who have begun childbearing is slightly higher
than the national average (12.1%). Among all
contraceptive users, most women choose injection (54%) or oral contraceptives (20%). Other
methods include implants (13%), IUD (8%), tubal
ligation/vasectomy (3%), or traditional methods
(2%).

injection,
54%
pill, 20%
implant, 13%
traditional
methods, 2%

IUD, 8%
permanent,
3%

2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

-1 CEONC hospital / district

1 / district
1 / 500,000 pop.

Hospitals with CEONC 1

Not reported

In-hospital OBGYN

--

1 / 12,711 pregnant
women

In-hospital pediatricians

--

1 / 11,592 newborn

(WHO minimum standard:


one / 500,000 pop.)

Puskesmas
(primary health centers)

129

One PHC / 30,000 pop.

1 / 31,049 pop.

General practitioner in
Puskesmas

122

--

1/ 32,831 pop.

Puskesmas with bed

25

--

19% of all puskesmas


74% of all puskesmas

4 / district

The total fertility rate (2.4) and crude birth rate (27.0) are higher than the national average. The

Contraceptive Methods Used


(IDHS 2002/3)

Puskesmas BEONC

95

(WHO minimum standard:


One / 125,000 pop.)

Average 10/district; 1 of
9 districts has none
1 / 42,162 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.

Provincial Reproductive Health & MPS Profile of Indonesia

191

ntb
Health Facilities

Access to Basic Emergency Obstetric Care (BEONC or PONED)

West Nusa Tenggara reports only 12 hospitals 9 public and only 3 private. There are only 9
hospital-based specialists in Ob/Gyn and pediatrics in the province.

A high proportion of puskesmas (95%) are reported to have received training and certification in
Basic Emergency Obstetric and Neonatal Care (BEONC). The current World Health Organization
(WHO) recommended standard for BEONC facilities is 1 for every 125,000 people. Indonesia has
adopted this indicator, but translated it to mean at least four BEONC facilities for each district.

All 9 public hospitals are certified as providers of Comprehensive Emergency Obstetric and Neonatal Care (CEONC) with 1-2 per district, except for Kab Sumbawa and Kota Bima, which report
none.
West Nusa Tenggara has 129 puskesmas (primary health centers) with a similar number of puskesmas-based general practitioners (122). Nearly 1 in 5 puskesmas (19%) has a bed for in-patient
care. The population covered by each puskesmas, on average, is slightly above the recommended standard.

There is a reported range of 1-28 BEONC facilities per district, with a population of only about
42,000 supported by each BEONC. The reported distribution of BEONC facilities is poor; an
additional 8 would be required for every district to have 4 BEONC. However, according to the
population size of West Nusa Tenggara districts, the total additional number of BEONC facilities
recommended is only 2. The cost per puskesmas team (3 persons) to be trained in BEONC is
IDR 9.3 million (3.1 per person).

Health Personnel

Primary Health Care Indicators

HEALTH PERSONNEL
2001
2005
% Change
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in BEONC
Total TBA
Trained TBA
TBA with kit
1
2

Not reported
Not reported

11
12

---

Not reported

175

--

Not reported

Not reported

--

601

851

42%

601

583

3%

601
Not reported
Not reported
Not reported
Not reported
Not reported

583
142 1
304
5763
5116
5116

3%
------

1 / 22,888 population

1 / 4707 population
71% of villages have village midwife
1 / 6870 population
Not calculated 2
1 / 13,176 population
89% of all TBA

Five of 9 districts (Kab Sumbawa, Kab Sumbawa Barat, Dompu, Kab Bima, Kota Bima) did not report this indicator.
Among the 4 reporting districts, the proportion of APN trained midwives is 43%.

The total number of specialists in West Nusa Tenggara is small, with one Ob/Gyn for every 364,000
and one pediatrician for every 334,000 people. The coverage of GPs meets the recommended
standard. Population coverage of midwives is below the recommendation; an additional 484
midwives would be needed to meet the standard of 1/3000. Only 71% of all villages are reported
to have a midwife living in the village, with little change in coverage since 2001.
The proportion of midwives trained in APN has not been calculated due to under-reporting, but
among the 4 districts that did report this indicator, 43% of midwives there had received APN training. The proportion of Midwives trained in LSS is higher than most provinces at 36%.

192

The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in West Nusa Tenggara of 27.0 (BPS, 2000), the reported pregnancies
are about 5% lower than the estimated pregnancies, and reported deliveries are also about 4%
lower than estimated deliveries. The proportion of deliveries to pregnancies, and newborn to
deliveries is valid and consistent with the country overall, further supporting the accuracy of the
reported events. The likely explanation for the small discrepancy is that the crude birth rate is
actually below 27.
DENOMINATORS FOR KEY
INDICATORS
Reported pregnancies
Reported deliveries
Reported newborn

Number

114,403
108,871
104,328

2.86% of total population


95.2% of reported pregnancies
95.8% of reported deliveries

Ratio of reported / estimated 1


95.3
95.9
--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.

A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.
Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the population may be higher than reported, or there is some double-counting of
events.
Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Antenatal Care Coverage


Among reported pregnancies, 90% of the women
attended at least one antenatal visit (ANC1). This
drops to 83% coverage of 4 total antenatal visits
(ANC4), which is very close to the 2007 target of
84%. Although ANC1 coverage is relatively good,
the difference between ANC4 and ANC1 means

Provincial Reproductive Health & MPS Profile of Indonesia

Antenatal Care Coverage 2005


ANC1 & 4
83%

no ANC
10%

ANC1 only
7%

ntb
that over 7,700 women who have accessed antenatal care once do not obtain the minimum standard of 4 antenatal visits. These women are either not adhering to the recommended antenatal
schedule or are accessing ANC too late to reach 4 visits. Quality of care, community awareness,
and logistical accessibility factors likely account for these missed opportunities. Over 11,000
pregnant women never accessed any antenatal care in West Nusa Tenggara.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in West Nusa Tenggara. More than 91% of women report having their blood
pressure measured; about 87% have their weight measured and receive iron tablets, and 97%
report having an abdominal examination. However, only 35% report being informed of signs of
pregnancy complications and only 23% gave a blood sample. Although West Nusa Tenggara has
relatively good quality indicators for antenatal care compared to the country overall, these last two
indicators represent critical components of antenatal care and should be improved upon further.
There is minimal variation in reported antenatal coverage by most districts, however, one district, Kab
Sumbawa, reports low rates of ANC1 (78%) and ANC4 (69%) compared to the provincial average.

Skilled Birth Attendance


Place of Delivery (IDHS, 2002/3)

Postpartum (Neonatal) Care Coverage


The IDHS estimates that only 12% of all births are officially registered in West Nusa Tenggara,
which is the lowest of all provinces in Indonesia. About 81% of all reported newborn attend the
first and second neonatal visits (KN1, KN2) and only 2% attend KN1 only. The IDHS found
similar rates of postpartum/neonatal care attendance, and similar rates of missing care altogether
(16%).
Birth Registration and Postnatal Care (IDHS, 2002/3)

40.0%

SBA
76%

20.0%
0.0%

public health private health


facility
facility

home

other /
missing

West Nusa Tenggara

21.8%

5.6%

64.2%

8.3%

Indonesia

9.2%

30.5%

59.0%

1.2%

60.0%
40.0%
20.0%
Ob/Gyn or midw ife or
GP
nurse

TBA

relative or
other

nobody

West Nusa Tenggara

5.9%

44.2%

46.5%

3.0%

0.0%

Indonesia

11.0%

55.3%

31.5%

1.3%

1.1%

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005
100.0%

k4

20.0%
0.0%

KN1 only,
2%

birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

West Nusa Tenggara

11.9%

60.5%

13.3%

10.0%

16.3%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

In Indonesia one of the indicator measuring


progress toward making pregnancy safer is
the rate of pregnant women detected as at
risk by the community, including cadres, TBAs
or other lay persons (i.e. non-health professionals). Indonesia adopted that 20% of all
pregnant women will need medical attention
during pregnancy or delivery, or nearly 23,000
pregnant women in West Nusa Tenggara annually (20% of all pregnant women reported).

Pregnancy Risk Detection


and Management of Complications
80.0%
60.0%
40.0%
20.0%
0.0%

detected by
community

detected by
health provider

maternal
complications

denominator=20% reported
pregnancies

36.2%

73.6%

37.1%

denominator=all pregnant
w omen

7.3%

14.7%

7.4%

Overall, only 36% of this total number of women were detected as being at risk by community
members and 74% were detected by a health provider (denominator adjusted, applicable to reporting districts only).

50.0%
0.0%

60.0%

Risk Detection and Management of Complications

Assistance During Delivery (IDHS, 2002/3)

0.0%

80.0%

40.0%

no
postnatal /
neonatal
care, 17%

60.0%

The IDHS estimated (2002/3) that fewer


than 6% of women are attended by a doctor at delivery; 44% by a nurse midwife,
and nearly half (50%) by a TBA, relative
or other attendant. These data are somewhat inconsistent with HIS reported data,
even for earlier years which consistently
reported higher rates of SBA coverage.

Variation in antenatal care shows no significant trend, but SBA coverage has increased about 5
percentage points since 2001.

KN1 &
KN2, 81%

80.0%

2005

Over 3 out of 4 (76%) of all reported deliveries are attended by a skilled health professional (SBA=skilled birth attendant). This
coverage is moderate, but still falls below
the recommended target for 2007 (82%).
More than 26,000 women delivered without
a skilled attendant in West Nusa Tenggara
in 2005.

There is minimal variation in reported SBA coverage by most districts, however, two districts, Kab
Loteng and Kab Sumbawa, report lower rates of SBA coverage (66% and 68% respectively) than
the provincial average.

Postpartum / Neonatal Care


Coverage 2005

Skilled Birth Attendant Coverage

no SBA
24%

Over 27% delivered at a health facility (mostly public), and 64% delivered at home (IDHS).

2001

2002

2003

2004

2005

83.0% 85.6% 86.1% 80.3% 83.3%

SBA 70.9% 89.7% 75.3% 72.3% 75.8%

Only 37% of all expected maternal complications (20% of pregnancies) were managed by the
health care system at primary or tertiary levels of care. The national target for obstetric complica-

Provincial Reproductive Health & MPS Profile of Indonesia

193

ntb
tions management is 60% by 2007 and 80% by 2010. West Nusa Tenggara is below national
expectations on this indicator.
Management of neonatal complications (estimated to be 25% of newborn born) appears to be
significantly lower. While the national target for 2007 is 60%, increasing to 80% in 2010, West
Nusa Tenggara reports managing about 14% of all expected neonatal complications.

Maternal and Neonatal Deaths

The reported stillbirth rate cannot be calculated because stillbirths were not reported. The national estimate is 17 / 1000 deliveries.

Hospital Management of Maternal and Neonatal Complications

There were 108 maternal deaths reported in


West Nusa Tenggara in 2005, about 2.6% of
all reported maternal deaths in Indonesia.
The estimated maternal mortality ratio (MMR)
is 104 / 100,000 live births. This is smaller
than national estimates (MMR=230, range
58 to 440, WHO/UNICEF/UNFPA, 2000 or
MMR=307, IDHS, 2002/3) and suggests under-reporting. West Nusa Tenggara probably
has among the higher rates of maternal mortality in Indonesia.

Causes of Maternal Deaths, 2005


other /
unknown
36%
infection
5%

bleeding
45%

eclampsia
14%

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reportednewborn)
140

130

131

113

Number

% of Hospital
Cases

% Coverage
(reported pregnancies) 1

3247

--

2.9% of all pregnancies

2085

64.2

--

Case fatality rate 3

10

0.48

Hospital admissions due to abortion


Caesarean sections

550
826

16.9
25.4

HOSPITAL CASES
OB/GYN cases treated at hospital
(includes normal deliveries)
Complicated OB/GYN cases treated
at hospital 2

114

It should be noted that more than one-third of all maternal deaths are not attributed to any immediate cause of death. More importance should be attached to correctly diagnosing and recording
causes of maternal deaths in order to more closely track progress toward effective management
of obstetric complication and identify potential interventions to reduce maternal mortality.
The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based
on reported data, West Nusa Tenggara has a neonatal mortality rate of only 7.4 compared to a
national estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely
that the West Nusa Tenggara data on neonatal mortality are accurate enough to utilize as an outcome indicator. According to IDHS 2002/2003, the neonatal mortality rate is 24/1000 birhts. This
province need some effort to achive the 2009 target, 15/1000 briths.
The ratio of early to late neonatal deaths cannot be calculated because neonatal deaths were not

8.5% of reported maternal


deaths (118 in 2004) occurred
in hospital
-_0.8% of all deliveries

Denominators from 2004 data were pregnancies: 113,576 deliveries: 108,599.


Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

The predominant cause of maternal death in


120
104
100
West Nusa Tenggara is bleeding, though ec80
lampsia plays a significant role. Key interven60
40
tions to reduce risk of hemorrhage should be
20
emphasized (iron deficiency anemia control,
0
2001
2002
2003
2004
2005
trained midwives, appropriate use of oxytord
cics in active management of 3 stage as per
national policy, access to safe blood transfusion/fluid replacement). Women with signs or symptoms of hypertensive disorders of pregnancy
should be treated properly and actively referred to specialist care at a hospital, since early delivery by c-section is the most effective measure to prevent progression to eclampsia and death.

194

reported by age. However, in Indonesia, about three-quarters of all neonatal deaths are expected
to occur in the first 7 days of life suggesting the importance of improving quality and access to
pregnancy care, safer delivery and emergency neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis, and management of low birth weight newborn).

Reported data from hospitals in West Nusa


Tenggara indicate that fewer than 3% of all
deliveries occur in hospital. Nearly two-thirds
(64%) of these deliveries are classified as
complicated.
The case fatality rate for complications among
hospital deliveries is low at 0.5%, but only 9%
of all reported maternal deaths occurred in the
hospital.

Obstetric Complications at Hospital 2004

other /
unknown
44%

abortion
26%
infection
5.5%

eclampsia
10%

bleeding
14%

Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or community preparedness in recognizing risk and
making timely referrals. The status of maternal and neonatal mortality audits is not reported in the
HIS data, but should be tracked closely by individual hospitals, districts and provinces and would
be an important indicator to monitor nationally.
Nearly 17% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion practices in West Nusa Tenggara. More than 25% of all deliveries in hospital are by caesarean section. The c-section rate over all deliveries in the province is low at less than 1% and suggests that there are women delivering outside of hospitals who would have had better outcomes

Provincial Reproductive Health & MPS Profile of Indonesia

ntb
if delivered by c-section. Internationally, from 5-15% of women are expected to require delivery
by c-section for optimal maternal/neonatal outcome.

12. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.

Recommendations

13. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.

Coverage of health personnel and service inputs


1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.
2. Increase the number of BEONC facilities over the province. Ensure minimum standards of
distribution of BEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife.
4. Improve utilization of trained midwives, and improve access to hospitals in case of delivery
or obstetric complication. Reduce the number of women who deliver with a TBA and/or at
home.
5. Investigate the reasons behind the difference between ANC4 and ANC1 rates of attendance. Who are these women entering the system but not being retained? Why do they
drop out?
6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries, especially in rural and hard-to-access areas.
8. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
9. Investigate the possible reasons behind low birth registration rates and develop strategies
to encourage higher registration rates among the community, health providers, and bureaucrats.

BEONC UNMET NEED ACCORDING TO STANDARDS


Total UnTotal
#
met Need
District
popula- BEONC
(MOH:
tion
in 2005
4 / district)
1
2
3
4
5
6
7
8
9

Kota Mataram
Kabupaten Lobar
Kabupaten Loteng
Kabupaten Lotim
Kabupaten Sumbawa
Kab. Sumbawa Barat
Kabupaten Dompu
Kabupaten Bima
Kota Bima

339,154
708,687
776,948
1,012,853
94,839
364,125
190,796
401,923
116,035

1
8
21
28
1
16
6
12
2

TOTAL

4,005,360

95

COVERAGE OF MIDWIFE PERSONNEL


Total reported
District
deliveries
1
2
3
4
5
6
7
8
9

Kota Mataram
Kabupaten Lobar
Kabupaten Loteng
Kabupaten Lotim
Kabupaten Sumbawa
Kab. Sumbawa Barat
Kabupaten Dompu
Kabupaten Bima
Kota Bima

TOTAL

8,925
18,900
20,475
27,294
10,120
2,520
6,151
11,329
3,157

108,871

Pop. /
BEONC

3
0
0
0
3
0
0
0
2

339,154
88,586
36,998
36,173
94,839
22,758
31,799
33,494
58,018
1 / 42,162
8
population

Total APN midwives


10
25
65
42
Not reported
Not reported
Not reported
Not reported
Not reported
142
(1 / 532 deliveries in reporting districts)

WHO recUnmet
ommended
need
coverage
(WHO)
(1 / 125,000)
3
6
6
8
1
3
2
3
1

2
0
0
0
0
0
0
0
0

33

Total BEONC midwives


12
67
69
41
3
30
25
52
5
304
1 / 358 pregnant women)

10. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


11. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more
accurate monitoring of changes over time in management of pregnancy and obstetric risk.

Provincial Reproductive Health & MPS Profile of Indonesia

195

ntb
KEY INDICATORS AND NATIONAL TARGETS

West Nusa Tenggara


2001

2005 *

ANC1 (K1)

92

90

ANC4 (K4)

83

SBA deliveries
Postpartum / Neonatal visit (KN1)

National Target
2007

2010

83

84

95

71

76

82

90

87

83

83

90

Risk detection of pregnant women by community

Not reported

36.2

Obstetric complications managed

Not reported

37.1

60

80

Neonatal complications managed

Not reported

14.2

60

80

Caesarian section rate (% of hospital deliveries)

20.8

25.4 *

Caesarian section rate (% of reported deliveries)

0.7

0.8 *

Hospital OB/GYN cases as % of all pregnancies

2.8

2.9 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

130

104

* c-section and hospital case data from 2004.

196

Provincial Reproductive Health & MPS Profile of Indonesia

EAST NUSA TENGGARA


(NTT)

he total population of East Nusa Tenggara is 4.2


million, accounting for 2% of the total population in Indonesia, and 36% of the population in
the region (Bali, East and East Nusa Tenggara).
East Nusa Tenggara is divided into 16 districts (15 kabupaten + 1 kota [city]) with a total of 2742 villages. There
are over 500 islands in NTT, but the three most populated are Flores, Sumba and West Timor. The capital is
Kupang on West Timor.

GEOGRAPHY
Total land area (km )

46,138

Number of districts

16

Kabupaten (regencies)

15

Kota (municipalities)

Kecamatan (sub-districts)

203

Kelurahan/Desa (villages)

2742

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

East Nusa Tenggara has a far lower urban population


(18%) and higher poor population (28%) compared to
the national average. Adult female literacy is significantly lower than the national rate at 83%.
SOCIAL DEMOGRAPHY

Total population (2005) 1


Percent urban population (2005) 2
Percent poor population (2004) 2

East Nusa Tenggara

National

4,200,596
18
28

220,659,431
48
17

Adult female literacy rate (2004) 2

83

87

Population density (km sq.; 2005) 2

87
Male: 62
Female: 66
1.54
984,620 3
4.1
25.2
10.6
27.5
16.7

116
Male: 64
Female: 68
1.34
51,732,453 4
2.6
22.0
10.4
56.7
8.6

Life expectancy at birth (2002) 2


Annual growth rate (2000-2005) 2
Women of reproductive age
Total fertility rate / 1000 women 6
Crude birth rate / 1000 pop. (2000) 5
Percentage of women 15-19 who have begun childbearing 6
Modern contraceptive prevalence (%) 6
Unmet need for contraception (%) 6

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total
population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1
2

The total fertility rate (4.1) and crude birth rate (25.2) are higher than the national average. The
modern contraceptive prevalence rate is less than half (28%) of the national rate, but the percentage of young women who have begun childbearing is similar to the national average (10.6%).

Among all contraceptive users, most women choose


injection (42%), traditional methods (22%), IUD
(16%) or oral contraceptives (9%).

Health Facilities

Contraceptive Methods Used


(IDHS 2002/3)
injection,
42%

pill, 9%
IUD, 16%

traditional
methods,
22%
implant, 5%

permanent,
6%

East Nusa Tenggara reports only 25 hospitals 15


public and 10 private. There are 11 hospital-based
specialists in Ob/Gyn and 12 in pediatrics. These data are not reported by several districts, so
may under-estimate coverage.
The number of hospitals that are certified as providers of Comprehensive Emergency Obstetric
and Neonatal Care (CEONC) was not reported in years 2002-2005. The last reported number
was in 2001 where there was one for each of the 14 districts in NTT at that time. These data
should be updated and verified.
East Nusa Tenggara has 231 puskesmas (primary health centers) with far fewer puskesmas-based
general practitioners (156). Over 1 in 4 puskesmas (29%) has a bed for in-patient care. The population covered by each puskesmas, on average, meets the recommended standard.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


Only 18% of all puskesmas are reported to have received training and certification in Basic Emergency Obstetric and Neonatal Care (BEONC). The current World Health Organization (WHO)
recommended standard for BEONC facilities is 1 for every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least four BEONC facilities for each district.
There is a reported range of 1-4 BEONC facilities per district, with a population of only about
100,000 supported by each BEONC. The reported distribution of BEONC facilities is relatively
good; however, an additional 22 would be required for every district to have 4 BEONC. According
to the population size of East Nusa Tenggara districts, the minimum additional number of BEONC
facilities recommended is only 2. The cost per puskesmas team (3 persons) to be trained in
BEONC is IDR 9.3 million (3.1 per person).

Provincial Reproductive Health & MPS Profile of Indonesia

197

NTT
2005
Indonesia miniCoverage
mum standard
Public
Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

Hospitals with CEONC

In-hospital OBGYN
In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in
Puskesmas
Puskesmas with bed

15 2

10 3

1 CEONC hospital
/ district

Not reported

11 4
12 5

-(WHO minimum
standard:
one / 500,000 pop.)
Not reported -1 / 11,085 pregnant women
Not reported -1 / 9153 newborn
One PHC / 30,000
231
1 / 18,184 pop.
pop.

156

66

--

1/ 26,927 pop.

--

29% of all puskesmas


18% of all puskesmas

4 / district
Puskesmas BEONC

--

42

(WHO minimum
standard:
One / 125,000
pop.)

Average 2-3/district; All


districts report at least one
1 / 100,014 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.


2
One district (Kab. Kupang) did not report this indicator.
3
Seven districts (Kota Kupang, TTS, Belu, Alor, Manggarai, Manggarai Barat, Rote Ndao) did not report this indicator.
4
Five districts (Kab Kupang, TTS, Lembata, Flotim, Manggarai Barat) did not report this indicator.
5
Four districts (Kab Kupang, Alor, Lembata, Flotim) did not report this indicator.
6
One district (Rote Ndao) did not report this indicator.
1

Health Personnel
The total number of specialists in East Nusa Tenggara is very small, with one Ob/Gyn and one
pediatrician for every 600,000. The coverage of GPs meets the recommended standard. Population coverage of midwives also meets the recommendation of 1/3000. However, only 55% of
all villages are reported to have a midwife living in the village, and this has decreased 12% since
2001.
The proportion of midwives trained in APN is only 14%, and the proportion of Midwives trained in
BEONC is not reported.

Primary Health Care Indicators


The Ministry of Health has adopted standard formulas for calculating the annual expected number
of pregnancies and deliveries in a given area based on population size and crude birth rate. Assuming a crude birth rate in East Nusa Tenggara of 27.0 (BPS, 2000), the reported pregnancies
are about 4% higher than the estimated pregnancies, and reported deliveries are 4% higher than
estimated deliveries. The proportion of deliveries to pregnancies, and newborn to deliveries

198

is valid and consistent with the country overall, further supporting the accuracy of the reported
events. The likely explanation for the small discrepancy between reported and estimated events
is that the crude birth rate may be higher than 27, or the population may be higher than estimated.
HEALTH PERSONNEL
2001
2005
% Change Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians
Primary health center general
practitioners
(One GP / 30,000 pop.)
Nurses trained in ANC
Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN

Not reported
Not reported

71
71

---

78

160 2

105%

Not reported

50 3

--

1863

2224 2

19%

1712

1500 2

12%

1712
Not reported

1359 4
312

21%
--

Midwives trained in BEONC

Not reported

88 5

--

6363
5311
3561

7816 6
5807 6
3629 7

22%
9%
2%

Total TBA
Trained TBA
TBA with kit

1 / 26,254 population

1 / 1889 population
55% of villages have village midwife
1 / 3091 population
14% midwives
Not calculated due to under-reporting
74% of all TBA
46% of all TBA

Nine districts (Kota Kupang, TTS, Belu, Alor, Lembata, Ende, Manggarai, Manggarai Barat, Rote Ndao) did not report this
indicator.
2
One district (Rote Ndao) did not report this indicator.
3
Eleven districts (Kota Kupang, Kab Kupang, TTU, Lembata, Flotim, Sikka, Ende, Manggarai Barat, Sumba Timur, Sumba
Barat, Rote Ndao) did not report this indicator.
4
Two districts (Manggarai Barat, Rote Ndao) did not report this indicator.
5
Nine districts (Kota Kupang, Kab Kupang, TTS, TTU, Alor, Manggarai Barat, Sumba Timur, Sumba Barat, Rote Ndao) did
not report this indicator.
5
Six districts (Kota Kupang, Sikka, Manggarai Barat, Sumba Timur, Sumba Barat, Rote Ndao) did not report this indicator.
1

DENOMINATORS FOR
KEY INDICATORS
Reported pregnancies
Reported deliveries
Reported newborn

Number

121,935
115,147
109,837

2.90% of total population


94.4% of reported pregnancies
95.4% of reported deliveries

Ratio of reported
/ estimated 1
103.8
103.6
--

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000.

A standardized measure of the accuracy of reported data is if the ratio of reported / estimated is close to 100.

Ratios above 100 indicate that there are more reported events than estimated events, suggesting that the crude birth
rate may be higher than estimated, the popul ation may be higher than reported, or there is some double-counting of
events.

Ratios below 100 indicate that there are fewer reported events than estimated events, suggesting that the crude birth
rate may be lower than estimated, the population may be lower than reported, or there is under-reporting of events.
1

Antenatal Care Coverage


Among reported pregnancies, 93% of the women attended at least one antenatal visit (ANC1).

Provincial Reproductive Health & MPS Profile of Indonesia

NTT
This drops to only 66% coverage of 4 total antenatal
Antenatal Care Coverage 2005
visits (ANC4), which is substantially lower than the
ANC1 & 4
2007 target of 84%. Although ANC1 coverage is
66%
relatively good, the difference between ANC4 and
ANC1 only
ANC1 is very large, and means that over 33,000
27%
no ANC
women who have accessed antenatal care once
7%
do not obtain the minimum standard of 4 antenatal
visits. These women are either not adhering to the
recommended antenatal schedule or are accessing ANC too late to reach 4 visits. Quality of
care, community awareness, and logistical accessibility factors likely account for these missed
opportunities. Over 8,000 pregnant women never accessed any antenatal care in East Nusa
Tenggara.
The Indonesian Demographic Health Survey (IDHS, 2002/3) describes the components of antenatal care provided in East Nusa Tenggara. More than 93% of women report having an abdominal examination, 87% report having their blood pressure taken; 83% have their weight measured
and 78% receive iron tablets. However, only 34% report being informed of signs of pregnancy
complications and only 47% report giving a blood sample. These data show that the quality of
antenatal care may be low in many places, and that critical components of good antenatal care
are not always provided.
There is minimal variation in reported antenatal coverage by most districts.

and 85% delivered at home (IDHS).


There is minimal variation in reported SBA
coverage by most districts, however, three
districts, TTS (50%), Belu (34%) and Manggarai Barat (51%), report lower rates of SBA
coverage compared to the provincial average.

100.0%
50.0%
0.0%

2001

2002

2003

2004

2005

57.0% 61.7% 68.0% 58.6% 66.0%

k4

SBA 59.2% 58.1% 65.8% 53.8% 67.2%

Trends in antenatal and SBA coverage from


2001 to 2005 show moderately consistent increases in antenatal care (ANC4) by about 9 percentage points, and increases in SBA coverage by about 8 percentage points.

Postpartum (Neonatal) Care Coverage


The IDHS estimates that only 24% of all births are officially registered in East Nusa Tenggara,
which is less than half the national average. About 76% of all reported newborn attend the first
and second neonatal visits (KN1, KN2) and 3% attend KN1 only. The IDHS found similar rates of
postpartum/neonatal care attendance, and lower rates of missing care altogether (16%).
Birth Registration and Postnatal Care (IDHS, 2002/3)

Postpartum / Neonatal Care


Coverage 2005

80.0%
60.0%

Skilled Birth Attendance

KN1 &
KN2, 76%
no
postnatal /
neonatal
care, 21%

Place of Delivery (IDHS, 2002/3)

Skilled Birth Attendant Coverage


2005
no SBA
33%

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005

100.0%
80.0%

40.0%
20.0%
0.0%

KN1 only,
3%

birth
postnatal
registration 0-2 days

postnatal
3-6 days

postnatal
7-41 days

no
postnatal

East Nusa Tenggara

24.1%

61.5%

3.7%

10.0%

16.3%

Indonesia

53.5%

61.8%

12.7%

7.9%

17.5%

60.0%

SBA
67%

40.0%
20.0%
0.0%

Only 2 out of 3 (67%) of all reported deliveries are attended by a skilled health
professional (SBA=skilled birth attendant).
This coverage is falls far below the recommended target for 2007 (82%). More than
37,700 women delivered without a skilled
attendant in East Nusa Tenggara in 2005.

public health private health


facility
facility

home

other /
missing

East Nusa Tenggara

9.4%

3.6%

85.4%

1.6%

Indonesia

9.2%

30.5%

59.0%

1.2%

Risk Detection and Management of Complications

Assistance During Delivery (IDHS, 2002/3)


80.0%
60.0%
40.0%
20.0%
0.0%

Ob/Gyn or midw ife or


GP
nurse

TBA

relative or
other

nobody

East Nusa Tenggara

2.3%

34.1%

65.9%

6.9%

1.3%

Indonesia

11.0%

55.3%

31.5%

1.3%

1.1%

The IDHS estimated (2002/3) that only


about 2% of all women are attended by a doctor at delivery; 34% by a nurse midwife, and nearly
73% by a TBA, relative or other attendant. Only 13% delivered at a health facility (mostly public),

In Indonesia one of the indicator measuring


progress toward making pregnancy safer is
the rate of pregnant women detected as at
risk by the community, including cadres,
TBAs or other lay persons (i.e. non-health
professionals). Indonesia adopted that
20% of all pregnant women will need medical attention during pregnancy or delivery,
or more than 24,000 pregnant women in
East Nusa Tenggara annually (20% of all
pregnant women reported).

Pregnancy Risk Detection


and Management of Complications
60.0%
40.0%
20.0%
0.0%

detected by
community

detected by
health provider

maternal
complications

denominator=20% reported
pregnancies

14.2%

55.8%

25.4%

denominator=all pregnant
w omen

2.8%

11.2%

5.1%

Overall, only 14% of this total number of women was detected as being at risk by community

Provincial Reproductive Health & MPS Profile of Indonesia

199

NTT
members and 56% were detected by a health provider (denominator adjusted, applicable to reporting districts only).

indicator. According to IDHS 2002/2003, the neonatal mortality rate is 131/1000 birhts. This province need high effort to achive the 2009 target, 15/1000 briths.

Only 25% of all expected maternal complications (20% of pregnancies) were managed by the
health care system at primary or tertiary levels of care. The national target for obstetric complications management is 60% by 2007 and 80% by 2010. East Nusa Tenggara is below national
expectations on this indicator.

The ratio of early to late neonatal deaths is lower than expected at 58%. In Indonesia, about
three-quarters of all neonatal deaths are expected to occur in the first 7 days of life suggesting
the importance of improving quality and access to pregnancy care, safer delivery and emergency
neonatal care (e.g. resuscitation, infection prevention, early detection and treatment of sepsis,
and management of low birth weight newborn).

Management of neonatal complications (estimated to be 25% of newborn born) appears to be


significantly lower. While the national target for 2007 is 60%, increasing to 80% in 2010, East
Nusa Tenggara reports managing about 8% of all expected neonatal complications.

Hospital Management of Maternal and Neonatal Complications

Maternal and Neonatal Deaths


There were 330 maternal deaths reported in East
Nusa Tenggara in 2005, about 8% of all reported
maternal deaths in Indonesia. The estimated maternal mortality ratio (MMR) is 300 / 100,000 live
births. This is within the range of national estimates
(MMR=230, range 58 to 440, WHO/UNICEF/UNFPA, 2000 or MMR=307, IDHS, 2002/3) and
while there is likely to be under-reporting,
East Nusa Tenggara is also likely to have
one of the highest Mrs. in the country.
400

Causes of Maternal Deaths, 2005


bleeding
58%
other /
unknown
20%

infection
12%

eclampsia
10%

Maternal Mortality Ratio 2001-05


(deaths / 100,000 reported newborn)
335

374

350
300
295
290
The predominant cause of maternal death
300
250
in East Nusa Tenggara is bleeding, though
200
infection and eclampsia play significant
150
100
roles. Key interventions to reduce risk of
50
hemorrhage should be emphasized (iron
0
2001
2002
2003
2004
2005
deficiency anemia control, trained midwives, appropriate use of oxytocics in active management of 3rd stage as per national policy, access to safe blood transfusion/fluid replacement). Women with signs or symptoms of hypertensive disorders of pregnancy should be treated
properly and actively referred to specialist care at a hospital, since early delivery by c-section is
the most effective measure to prevent progression to eclampsia and death.

It should be noted that 20% of all maternal deaths are not attributed to any immediate cause of
death. More importance should be attached to correctly diagnosing and recording causes of
maternal deaths in order to more closely track progress toward effective management of obstetric
complication and identify potential interventions to reduce maternal mortality.
The number of reported stillbirths and neonatal deaths indicates serious under-reporting. Based
on reported data, East Nusa Tenggara has a neonatal mortality rate of only 8.6 compared to a
national estimate of 18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that
the East Nusa Tenggara data on neonatal mortality are accurate enough to utilize as an outcome

200

The reported stillbirth rate is 11.7 / 1000 estimated deliveries in East Nusa Tenggara compared to
the national estimate of 17.

Reported data from hospitals in East Nusa Tenggara indicate that fewer than 5% of all deliveries
occur in hospital. Over 28% of these deliveries are classified as complicated.
The case fatality rate for complications among hospital deliveries is moderate at 1.3% (WHO>1%),
but only 7% of all reported maternal deaths occurred in the hospital.
HOSPITAL CASES

% Coverage
Number % of Hospital Cases (reported pregnancies)
1

OB/GYN cases treated at hospital


(includes normal deliveries)

5671

--

4.6% of all pregnancies

Complicated OB/GYN cases treated


at hospital 2

1608

28.4

--

Case fatality rate 3

21

1.31

7.1% of reported maternal


deaths (295 in 2004) occurred in hospital

Hospital admissions due to abortion

740

13.1

--

Caesarean sections

920

16.2

0.8% of all deliveries

Denominators from 2004 data were pregnancies: 123,632; deliveries: 115,626.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Hospital data do not allow for more detailed analysis of how long after admission the mother
died. This information would reflect whether interObstetric Complications at Hospital 2004
ventions needed to reduce maternal deaths should
emphasize hospital practices / quality of care or
abortion
community preparedness in recognizing risk and
other /
45%
unknown
making timely referrals. The status of maternal and
36%
bleeding
neonatal mortality audits is not reported in the HIS
11%
data, but should be tracked closely by individual
infection
eclampsia
hospitals, districts and provinces and would be an
1.6%
6%
important indicator to monitor nationally.

Provincial Reproductive Health & MPS Profile of Indonesia

NTT
Over 13% of all hospital admissions are due to abortion, suggesting a high rate of unsafe abortion
practices in East Nusa Tenggara. Only around 16% of all deliveries in hospital are by caesarean
section. The c-section rate over all deliveries in the province is low at less than 1% and suggests
that there are some women delivering outside of hospitals who would have had better outcomes
if delivered by c-section. Internationally, from 5-15% of women are expected to require delivery
by c-section for optimal maternal/neonatal outcome.

Recommendations
Coverage of health personnel and service inputs
1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons be hind under-performance, and possible solutions.
2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.
3. Increase the number of midwives who have received APN and BEONC training. Ensure
that every puskesmas has at least one trained ANC midwife. Given the high MMR in NTT,
the priority should be to aggressively upgrade the technical skills of those attendants and
ensure adequate access to well-prepared facilities.
4. Investigate the reason behind low ANC1 coverage. Why do so many women never access
antenatal care? Investigate the reasons behind the difference between ANC4 and ANC1
rates of attendance. Who are these women entering the system but not being retained?
Why do they drop out?
5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.

accurate monitoring of changes over time in management of pregnancy and obstetric risk.
11. Investigate data quality and completeness of all health input data both facility and personnel. These data are critical for evaluating distribution of resources, and where to invest in
increasing health infrastructure to ensure equal access within the province.
12. Conduct periodic (monthly or quarterly) internal data consistency and logical checks at district and provincial levels to improve quality of data. Ensure complete data reporting from
all districts before finalizing annual data submissions.
BEONC UNMET NEED ACCORDING TO STANDARDS
WHO recomTotal
Total Unmet
# BEONC
Pop. / mended covpopulaNeed (MOH:
in 2005
BEONC
erage
tion
4 / district)
(1 / 125,000)

District
1 Kota Kupang

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

Unmet
need
(WHO)

263,694

131,847

Kupang

332,419

110,806

TTS

407,919

203,960

TTU

216,676

72,225

Belu

349,653

116,551

Alor

169,953

84,977

Lembata

125,025

62,513

Flotim

216,647

108,324

Sikka

278,380

69,595

Ende

238,586

79,529

Ngada

239,744

59,936

Manggarai

481,679

120,420

Manggarai Barat

180,058

90,029

Sumba Timur

202,312

67,437

Sumba Barat

393,475

196,738

Rote Ndao

104,376

1
42

3 104,376
22 100,014

1
34

0
2

TOTAL 4,200,596

8. Improve classification of maternal deaths by cause to reduce the proportion reported as


unknown.
9. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Data quality and reporting


10. Improve detection and reporting of maternal deaths, stillbirths and neonatal deaths for more

Provincial Reproductive Health & MPS Profile of Indonesia

201

NTT
COVERAGE OF MIDWIFE PERSONNEL
Total reported deDistrict
liveries

Total APN midwives

Total LSS midwives

1 Kota Kupang

6,917

10

Not reported

2 Kupang

7,894

15

Not reported

3 TTS

11,887

Not reported

4 TTU

6,889

20

Not reported

5 Belu

9,092

10

6 Alor

4,414

10

Not reported

7 Lembata

2,672

30

10

8 Flotim

5,610

30

9 Sikka

7,237

30

10 Ende

6,314

40

20

11 Ngada

6,245

30

20

12,715

20

22

13 Manggarai Barat

5,409

25

Not reported

14 Sumba Timur

5,518

20

Not reported

15 Sumba Barat

13,585

20

Not reported

2,749

Not reported

115,147

312
(1 / 369 deliveries)

88
1 / 1308 deliveries)

12 Manggarai

16 Rote Ndao
TOTAL

KEY INDICATORS AND NATIONAL TARGETS

East Nusa Tenggara


2001

2005 *

ANC1 (K1)

84

93

ANC4 (K4)

57

SBA deliveries
Postpartum / Neonatal visit (KN1)

National Target
2007

2010

66

84

95

59

67

82

90

62

79

83

90

19.4

14.2

Obstetric complications managed

Not reported

25.4

60

80

Neonatal complications managed

Not reported

8.0

60

80

Caesarian section rate (% of hospital deliveries)

14.5

16.2 *

Caesarian section rate (% of reported deliveries)

1.1

0.8 *

Hospital OB/GYN cases as % of all pregnancies

6.9

4.6 *

Maternal Mortality Ratio


(maternal deaths / 100,000 reported live births)

290

300

Risk detection of pregnant women by community

* c-section and hospital case data from 2004.

202

Provincial Reproductive Health & MPS Profile of Indonesia

MALUKU

he total population of Maluku is nearly 1.4


million, accounting for less than 1% of the
total population in Indonesia, and 28% of
the population in Maluku/Papua. Maluku is
divided into 8 districts (7 kabupaten + 1 Kota [cities])
with a total of 886 villages. The capital is Ambon.
Maluku has a significantly lower urban population
(26%) and substantially higher poor population
(31%) compared to the national average. Adult female literacy is also higher at 97%.

GEOGRAPHY
Total land area (km2)

47,350

Number of districts

Kabupaten (regencies)

Kota (municipalities)

Kecamatan (sub-districts)

62

Kelurahan/Desa (villages)

886

Source: Beberapa Indikator Penting SosialEkonomi Indonesia, Edisi Juli 2006, BPS.

SOCIAL DEMOGRAPHY

Maluku

National

Total population (2005) 1

1,379,877

220,659,431

Percent urban population (2005) 2

26

48

Percent poor population (2004) 2

31

17

97

87

27

116

Life expectancy at birth (2002) 2

Male: 64
Female: 67

Male: 64
Female: 68

Annual growth rate (2000-2005) 2

1.66

1.34

323,440 3

51,732,453 4

Total fertility rate / 1000 women 2

2.75

2.6

Crude birth rate / 1000 pop. (2000) 5

21.4

22.0

Percentage of women 15-49 who have ever used contraception 2

39.8

74.1

Modern contraceptive prevalence (%) 6

No DHS

56.7

Unmet need for contraception (%)

No DHS

8.6

Adult female literacy rate (2004)

Population density (km sq.; 2005)

Women of reproductive age

From provincial health data reports.


Beberapa Indikator Penting Sosial-Ekonomi Indonesia, Edisi Juli 2006, BPS.
3
Provincial website did not provide data tables on population by age and gender. This number calculated from total population, using national ratio of women of reproductive age to total population in Indonesia (23.44%).
4
From http://www.bps.go.id/sector/population/pop2000.htm, census data, table 7.
5
BPS 2000
6
IDHS 2002/3
1

modern contraceptive prevalence rate is not estimated as the IDHS was not conducted there.
However, the percentage of women 15-48 who have ever used contraception (40%) is far lower
than the national average (74%).

Health Facilities
Maluku reports 17 hospitals; 10 public and 7 private. There are only 10 Ob/Gyn and 9 pediatricians reported to staff those hospitals.
Only 6 of the public hospitals are certified provider of Comprehensive Emergency Obstetric and
Neonatal Care (CEONC). This leaves five districts with no CEONC coverage: M Tengah, M
Tenggara Barat, Aru, SBT and SBB.
2005
Indonesia minimum
Coverage
standard
Public Private
Rows bordered in red are below minimum standard

HEALTH FACILITIES

Total hospitals (general)

10

Hospitals with CEONC 1

Not reported

In-hospital OBGYN

--

In-hospital pediatricians
Puskesmas
(primary health centers)
General practitioner in Puskesmas
Puskesmas with bed

--

1 / 3278 pregnant
women
1 / 4261 newborn

132

One PHC / 30,000 pop.

1 / 10,454 pop.

68

--

1/ 20,292 pop.

40

--

30% of all puskesmas


31% all puskesmas

1 CEONC hospital / district


(WHO minimum standard:
one / 500,000 pop.)

The total fertility rate (2.7) and crude birth rate (21.4) are similar to the national average. The

4 / district
Puskesmas BEONC

41

(WHO minimum standard:


One / 125,000 pop.)

--

<1 / district
2 / 500,000 pop.

Average 5/district; 1 of
8 districts has none
1 / 33,656 pop.

Comprehensive Emergency Obstetric and Neonatal Care, 24 hour service.

Provincial Reproductive Health & MPS Profile of Indonesia

203

MALUKU
Maluku reports 132 puskesmas (primary health centers) which meets the recommended standard, but
far fewer puskesmas-based general practitioners (68). Only 30% of puskesmas are reported to have
beds for in-patient care.

Access to Basic Emergency Obstetric Care (BEONC or PONED)


One-third (31%) of all puskesmas, 41 facilities total, were reported to have received training and
certification in Basic Emergency Obstetric and Neonatal Care (BEONC). Only one district, Ambon, reports having zero BEONC facilities (and this is likely a reporting error).
The current World Health Organization (WHO) recommended standard for BEONC facilities is 1
for every 125,000 people. Indonesia has adopted this indicator, but translated it to mean at least
four BEONC facilities for each district.
For every district to have 4 BEONC, Maluku should have 32 BEONC facilities, even fewer than
it currently has. According to population size, the minimum total recommended number is only
11. However, the current distribution of BEONC facilities suggests that Maluku requires about 7
more. The cost per puskesmas team (3 persons) to be trained in BEONC is IDR 9.3 million (3.1
per person).

Maluku reports having one Ob/Gyn for every 150,000 population and one pediatrician for every
200,000 population. Coverage of GPs meets the recommended standard, as does coverage of
midwives. However, only 57% of all villages are reported to have a midwife living in the village.
Only 13% of all midwives are APN-trained, and fewer than half as many have received BEONC
training.
HEALTH PERSONNEL
2005
Coverage
(minimum standard)
Rows bordered in red are below minimum standard
OB/GYNs
Pediatricians

9
7

Primary health center general practitioners


(One GP / 30,000 pop.)

75

204

The Ministry of Health has adopted standard formulas for calculating the annual expected number of pregnancies and deliveries in a given area based on population size and crude birth rate.
Assuming a crude birth rate in Maluku of 21.4 (BPS, 2000), the estimated pregnancies and deliveries were clearly in error in 3 districts (M Tenggara Barat, SBT, SBB). Estimated events were
therefore utilized for all indicator calculations. The MOH formulas were used to estimate pregnancies and deliveries, and the multiplier used to estimate newborn (reported deliveries x 96.2%) was
calculated from all reported deliveries and newborn in Indonesia.
DENOMINATORS FOR KEY INDICATORS

Number

Estimated pregnancies 1

32,778

2.38% of total population

Estimated deliveries 1

31,006

94.6% of reported pregnancies

Estimated newborn

29,828

96.2% of reported deliveries

Estimated pregnancies are calculated according to the MOH formula: (total population * crude birth rate * 1.11)/1000.
Estimated deliveries are (total population * crude birth rate * 1.05)/1000. Estimated newborn are calculated according to 96.2%
of deliveries, which is the proportion reporting in Indonesia overall. Reported data for pregnancies, deliveries and newborn
could not be relied upon due to obvious errors in several districts (for example: reported pregnancies were <1% of estimated
pregnancies in one district, only 14% in another, and over 800% in a third).
1

Antenatal Care Coverage

Health Personnel

Nurses trained in ANC


Total midwives
(One / 3000 pop.)
Midwives living in the village
(One / village)
Midwives with a kit
Midwives trained in APN
Midwives trained in LSS
Total TBA
Trained TBA
TBA with kit

Primary Health Care Indicators

1 / 18,398 population

112
951

1 / 1451 population

509

57% of villages have village midwife

518
127
54
3298
2034
1173

1 / 2664 population
13% midwives
1 / 25,553 population

Among estimated pregnancies, 82% of the women


Antenatal Care Coverage 2005
attended at least one antenatal visit (ANC1). This
drops to 64% coverage of 4 total antenatal visits
ANC1 & 4
64%
(ANC4), which is far below the 2007 target of 84%.
While ANC1 coverage is moderate, the difference
ANC1 only
between ANC4 and ANC1 is also significant, sug18%
no ANC
18%
gesting that nearly 6000 women who have accessed
antenatal care once but do not obtain the minimum
standard of 4 antenatal visits. These women are
either not adhering to the recommended antenatal schedule or are accessing ANC too late to
reach 4 visits. Quality of care, community awareness, and logistical accessibility factors likely
account for these missed opportunities. An additional 5700 pregnant women never accessed
any antenatal care in Maluku.
There is significant variation in reported antenatal coverage by two districts. SBT reported only
3% ANC1 coverage and 2% ANC4 coverage, while SBB reported nearly 200% ANC1 coverage
and 144% ANC4 coverage. These data were retained in the indicator calculation because (1)
excluding them changed the final indicator very little, (2) they were consistently very low or very
high across both indicators, and (3) these were new districts (not present in 2004 data) and it is
possible that SBB counted SBTs data.

62% of all TBA


36% of all TBA
Provincial Reproductive Health & MPS Profile of Indonesia

MALUKU
Only 6% of maternal complications were reported to have been managed (only 3 districts reported) and management of neonatal
complications was not calculated because
only one district reported. The national target for obstetric or neonatal complications
management is 60% by 2007 and 80% by
2010.

Skilled Birth Attendance


Only 59% of all reported deliveries are attended by
a skilled health professional (SBA=skilled birth attendant). This leaves nearly 13,000 women delivering without any skilled birth attendant. The national
target for skilled birth attendance is 82% by 2007
and 90% by 2010; Maluku is far below this expectation.
Two districts were excluded from this coverage calculation because they reported
unrealistically low coverage rates (Aru: 6%
and SBT: 2%). If these low rates are valid,
the SBA coverage rate in Maluku is less
than 50%. One additional district, SBB,
reported coverage of only 30%.

Skilled Birth Attendant Coverage


2005

SBA
59%

no SBA
41%

Pregnancy Risk Detection


and Management of Complications
20.0%
15.0%
10.0%
5.0%
0.0%

detected by
community

detected by
health provider

maternal
complications

denominator=20% reported
pregnancies

0.6%

17.1%

5.7%

denominator=all pregnant
w omen

0.1%

3.4%

1.1%

Maternal and Neonatal Deaths

Antenatal Care and Skilled Birth


Attendant Coverage, 2001 - 2005
(no data reported for 2001-2002)

100.0%
50.0%
0.0%

2001 2002 2003 2004 2005


66.8%71.4% 64.6%

Antenatal and SBA coverage from 200163.2%40.5% 58.7%


SBA
2002 was not reported. Data from 20032005 show inconsistent reports. It cannot
be concluded that there was any improvement in coverage rates in Maluku, and fluctuations in
the data over the years suggest that there are problems in reporting accurate data.
k4

There were 77 maternal deaths reported in Maluku


in 2005, nearly 2% of all reported maternal deaths
in Indonesia. The estimated maternal mortality ratio (MMR) is 258 / 100,000 live births. This is within
range of national estimates (MMR=230, range 58
to 440, WHO/UNICEF/UNFPA, 2000 or MMR=307,
IDHS, 2002/3) and suggests that Maluku may have
among the highest MMRs in the country,
since almost every province appears to significantly under-reported maternal deaths.

Causes of Maternal Deaths, 2005


other /
unknown
26%
infection
17%

bleeding
47%

eclampsia
10%

Maternal Mortality Ratio, 2003-05


(deaths / 100,000 reported newborn)
(not reported 2001-02)

258
The predominant cause of maternal death
250
in Maluku is bleeding, though infection
173
200
and eclampsia play significant roles. Key
150
83
100
interventions to reduce risk of hemorrhage
50
should be emphasized (iron deficiency ane0
mia control, trained midwives, appropriate
2001
2002
2003
2004
2005
use of oxytocics in active management of 3rd
stage as per national policy, access to safe
blood transfusion/fluid replacement). Women with signs or symptoms of hypertensive disorders
of pregnancy should be treated properly and actively referred to specialist care at a hospital, since
early delivery by c-section is the most effective measure to prevent progression to eclampsia and
death.
300

Postpartum (Neonatal) Care Coverage


About 68% of all reported newborn attend the first
and second neonatal visits (KN1, KN2) and 3% attends KN1 only. These data are adjusted for the
same two districts (Aru and SBT) who reported extremely low coverage rates (10% and 3% for KN1
and KN2, respectively). Unadjusted coverage was
58% for KN1 and KN2 and 59% for KN1 only.

Postpartum / Neonatal Care


Coverage 2005
KN1 &
KN2, 58%

no
postnatal /
neonatal
care, 40%

KN1 only,
2%

Risk Detection and Management of Complications


In Indonesia one of the indicator measuring progress toward making pregnancy safer is the rate
of pregnant women detected as at risk by the community, including cadres, TBAs or other lay
persons (i.e. non-health professionals). Indonesia adopted that 20% of all pregnant women will
need medical attention during pregnancy or delivery, or over 6500 pregnant women in Maluku
annually (20% of all pregnant women reported).
Less than 1% of this total number of women was detected as being at risk by community members, and only 17% were detected by a health provider (denominator adjusted, applicable to
reporting districts only).

It should be noted that 26% of all maternal deaths are not attributed to any immediate cause of
death. More importance should be attached to correctly diagnosing and recording causes of
maternal deaths in order to more closely track progress toward effective management of obstetric
complication and identify potential interventions to reduce maternal mortality.
The number of reported stillbirths and neonatal deaths indicates under-reporting. Based on reported data, Maluku has a neonatal mortality rate of only 5.5 compared to a national estimate of
18 neonatal deaths per 1000 births (WHO, 2006). Therefore, it is unlikely that the Maluku data on
neonatal mortality are accurate enough to utilize as an outcome indicator.

Provincial Reproductive Health & MPS Profile of Indonesia

205

MALUKU
The ratio of early to late neonatal deaths is consistent with the expected ratio. About 72% of
neonatal deaths are reported to have occurred before 7 days, suggesting the importance of improving quality and access to pregnancy care, safer delivery and emergency neonatal care (e.g.
resuscitation, infection prevention, early detection and treatment of sepsis, and management of
low birth weight newborn).

Recommendations
Coverage of health personnel and service inputs

The reported stillbirth rate is 5.4 / 1000 estimated deliveries in Maluku compared to the national
estimate of 17.

1. Review each district highlighted by name in this document for under-performance or unmet
need (highlighted in bold in text and tables) to investigate apparent deficiencies (real or
poor data reporting?), reasons behind under-performance, and possible solutions.

Hospital Management of Maternal and Neonatal Complications

2. Increase the number of BEONC and CEONC facilities over the province. Ensure minimum
standards of distribution of BEONC and CEONC facilities across all districts, and correlation with population size.

HOSPITAL CASES
OB/GYN cases treated at hospital (includes
normal deliveries)
Complicated OB/GYN cases treated at
hospital 2
Case fatality rate 3
Hospital admissions due to abortion
Caesarean sections

Number

% of Hospi% Coverage
tal Cases (reported pregnancies) 1

1682

--

4.9% of all pregnancies

126

7.5

--

2.38

35
195

2.1
11.6

12.0% of reported maternal


deaths (25 in 2004) occurred
in hospital
-0.6% of all deliveries

Denominators from 2004 data were pregnancies: 34,330; deliveries: 32,770.


2
Excludes deliveries counted in the c-section column as these may also be counted in complication columns (leading to c-section). Includes cases counted in abortion column.
3
Obstetric deaths at hospital / obstetric complications treated. Excludes c-sections from the denominator, although deaths
reported in the c-section column are included in the numerator.
1

Reported data from hospitals in Maluku indicate


that nearly 5% of all deliveries occur in hospital and
only 8% of these deliveries are classified as complicated.
The case fatality rate for complications among hospital deliveries is high at 2.4%, but only 12% of all
maternal deaths occurred in hospital.

Obstetric Complications at Hospital 2004

other /
unknown
52%

abortion
28%
eclampsia
6%

bleeding
14%

4. Investigate the reason behind low ANC1 coverage. Why do so many women never access
antenatal care? Investigate the reasons behind the difference between ANC4 and ANC1
rates of attendance. Who are these women entering the system but not being retained?
Why do they drop out?
5. Increase the number of women who deliver with a skilled birth attendant and improve access to hospitals in case of delivery obstetric or complication.
6. Increase the proportion of newborn and postpartum mothers who receive postnatal care.
7. Improve management of obstetric and neonatal complications. Community awareness of
pregnancy risk, and active commitment to ensuring good referral systems could contribute
significantly toward even safer deliveries.
8. Improve classification of maternal deaths by cause to reduce the proportion reported as
unknown.
9. Initiate or strengthen Maternal and Neonatal Mortality audit at district and health facilities
level.

Hospital data do not allow for more detailed analysis of how long after admission the mother died.
This information would reflect whether interventions needed to reduce maternal de