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    Prof biranroadtomaternaldeathpelatihan ponek jakarta290812 Prof biranroadtomaternaldeathpelatihan ponek jakarta290812 Presentation Transcript

    • THE ROAD TO MATERNAL DEATH Biran Affandi Klinik Raden Saleh Department of Obstetrics and GynecologyFaculty of Medicine , University of Indonesia / Cipto Mangunkusumo General Hospital Jakarta Affandi B. The Road to Maternal Death . POKJANAS PONE , Jakarta , 29 August 2012
    • OBJECTIVES1. To overview Millennium Development Goals2. To review Status of Maternal & Neonatal Health in Indonesia3. To discuss ways in Improving Maternal Health in Indonesia Affandi B. The Road to Maternal Death . POKJANAS PONE , Makassar 19 Juli 2011
    • MELLINIUM DEVELOPMENT GOALS(MDGs)Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011
    • GOAL 4: Reduce child mortalityFamily planning saves infant lives.Spacing births and limitingunintended births increases childsurvival.•Currently, 2.7 million infant deathsare averted each year by theprevention of unintendedpregnancies. Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011
    • PROGRESS INDONESIA (4/8)4. Menurunkan Angka Kematian Anak  menjadi 1/3-nya (2015) Tantangan: -Sebab kematian pada anak (ISPA, komplikasi perinatal, & diare) -Kesehatan neonatal & maternal -Perlindungan & Pelayanan Kesehatan -Penerapan desentralisasi kesehatan
    • MMR in Indonesia, Selected other countries 700 620 600 500 440 400 Indonesia 350 India 300 270 240 Vietnam 200 SE asia 100 0 1990 1995 2000 2005 2008 Indonesia: 62% decline on 1990 levels, 5.4% annual change7 Trends In Maternal Mortality 1990-2008, Source: WHO , 2010
    • MDG 5: Improve maternal health– Target 5a: Reduce the maternal mortality ratio by ¾ (75%) • Indicator 5.1 Maternal mortality ratio (MMR) • Indicator 5.2 Proportion of births attended by skilled health personnel– Target 5b: Achieve universal access to reproductive health by 2015 • Indicator 5.3 Contraceptive prevalence rate (CPR) • Indicator 5.4 Adolescent birth rate • Indicator 5.5 Antenatal care coverage • Indicator 5.6 Unmet need for family planningAffandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011
    • PROGRESS INDONESIA (5/8)5. Meningkatkan Kesehatan Ibu  menurunkan angka kematian ¾-nya Tantangan: -Struktur penduduk  proporsi wanita subur tinggi meningkatkan kebutuhan lynn kesehatan -Penerapan desentralisasi kesehatan -Keterbatasan biaya & tenaga
    • Persalinan 1 tahun terakhir oleh Nakes menurut Provinsi 2010Sumber: Riskesdas 2010 11
    • Proporsi Persalinan menurut Tempat Melahirkan 70.0 60.0 55.4 50.0 43.2 Persen 40.0 30.0 20.0 10.0 1.4 0.0 Fasilitas kesehatan Polindes/Poskesdes Rumah/Lainnya Tempat Melahirkan • 51,9% persalinan ditolong bidan • 40,2% ditolong dukunSumber : Riskesdas 2010 12
    • Kesenjangan Pelayanan Antenatal K1 & K4 92.8 100 80 61.3 60 40 20 0 K1 K4Sumber: Riskesdas 2010 13
    • • Maternal mortality is an indicator of gross inequality, human rights abuse and development failure.• “All maternal health problems are preventable as long as the government pays attention and prioritizes maternal health.” Dr. S.T.Mathai, UNFPA , The Jakarta Post , 13 Jan. , 2010Affandi B. Kesehatan Reproduksi dan Upaya Kesehatan Maternal di Indonesia , Quo Vadis ? Orasi pada PIT XVIII-POGI , Jakarta , 7 Juli 2010
    • •Of the 11 countries that contribute to 65percent to global maternal death, five are inAsian countries includingIndonesia, Bangladesh, Pakistan , India andAfghanistan.•A high maternal mortality rate is anindicator of the status of poor functioning ofa country’s health system including lack ofsupportive and protective legal and policyenvironment. Dr. S.T.Mathai, UNFPA , The Jakarta Post , 13 Jan. , 2010Affandi B. Kesehatan Reproduksi dan Upaya Kesehatan Maternal di Indonesia , Quo Vadis ? Orasi pada PIT XVIII-POGI , Jakarta , 7 Juli 2010
    • Womens status• As measured by indicators such as level of education relative to men, age at first marriage, and reproductive autonomy, is a strong predictor of maternal mortality.• Economic dependency, especially multinational corporate investment, has a detrimental effect on maternal mortality that is mediated by its harmful impacts on economic growth and the status of women.• Support for developmental theory, a variant of modernization theory. Shen & Williamson . Soc Sci Med. 1999, 49:197-214
    • Three-pronged strategy to reducing maternal mortality■ Family planning to ensure that every birth is wanted■ Skilled care by a health professional with midwifery skills for every pregnant woman during pregnancy and childbirth■ Emergency Obstetric Care (EmOC) to ensure timely access to care for women experiencing complications. UNFPA , 2009
    • MOST POPULOUS COUNTRIES , 2009 COUNTRY POPULATION (Million) 1. China 1,346 2. India 1,198 3. U.S.A. 315 4. Indonesia 230 5. Brazil 194 Sources: United Nations (2009), World Population Prospect: The 2008 Revision;Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010
    • POPULATION IN INDONESIA (Million) 330 million 300.00 285 million 275.00 FAMILY PLANNING FAMILY PLANNING REDUCED 250.00 REDUCED 100 MILLION 80 MILLION 225.00 230 m 200.00 205 m 175.00 150.00 125.00 100.00 75.00 50.00 40.2 25.00 10.8 14.2 18.3 0.00 1600 1700 1800 1900 2000 2009Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010
    • CONTRACEPTIVE PREVALENCE INDONESIA , 1970-2007 80 70 61.4 % 60 % 57 % 60 48 % 50 40 26 % 30 20 5 % (?) 10 0 1970 1980 1987 1997 2002 2007Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010
    • PERENCANAAN KELUARGA1. Seorang wanita telah dapat melahirkan, segera setelah ia mendapat haid yang pertama (menarche)2. Kesuburan seorang wanita akan terus berlangsung, sampai mati haid (menopause)3. Kehamilan dan kelahiran yang terbaik, artinya risiko paling rendah untuk ibu dan anak, adalah antara 20-35 tahun4. Persalinan pertama dan kedua paling rendah risikonya5. Jarak antara dua kelahiran sebaiknya 2-4 tahunAffandi, 1984
    • POLA PERENCANAAN KELUARGA Fase Fase Fase Menunda Menjarangkan Tidak Hamil Kehamilan Kehamilan lagi 2-4 20 35Affandi, 1984
    • CONTRACEPTIVE METHODS RATIONALE CHOICE Phase Phase PhaseDIFFERING SPACING COMPLETING 2-4 - Pill - IUD - IUD - Steril - IUD - Inject. - Inject. - IUD - Conventional - Pill - Pill - Pill 20 35 - Implant - Inject. - Implant - Implant - Implant - Conventional - Conventional - Inject. - Steril - Conventional Affandi, 1984
    • BIRTH RATE STILL HIGH ! ! ! 4.5 – 5 Million/yearAffandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010
    • FAKTA1.Pascasalin OVULASI dapat terjadi dalam waktu 21 hari2.Pascakeguguran OVULASI dapat TERJADI dalam waktu 11hari Contraceptive choices for breastfeeding women .Journal of Family Planning and Reproductive Health Care 2004; 30(3): 181–189 Affandi B. Kontrasepsi Terkini dan IUD Pascaplasenta . Pertemuan Koordinasi Peningkatan KB Pascapersalinan di Rumah Sakit , Makassar 31 Agustus 2010
    • IUD-CuAffandi B. Perkembangan Kontrasepsi, Teknik Penapisan dan KB Postpartum , BPMPPKB, Balikpapan , 24 Juni 2010
    • • The postpartum insertion of IUDs has a number of advantages, including ease of insertion, availability of skilled personnel and appropriate facilities, and convenience for the woman.• Practitioners have been concerned about the possibility of higher expulsion, infection and perforation www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm rates. Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010
    • • Postplacental (preferably within 10 minutes after expulsion of the placenta) and immediate postpartum insertion during the first week after delivery (but preferably within 48 hours) are convenient effective and safe times to insert copper IUDs. {Managing Contraception 2005-2007, page 92} Affandi B. Perkembangan Kontrasepsi, Teknik Penapisan dan KB Postpartum , BPMPPKB, Balikpapan , 24 Juni 2010
    • Teknik Pemasangan AKDRAffandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010
    • Fundal placement• The way the IUD is inserted is more important than the design of the device.• Differences in IUD expulsion rates between centers participating in the trials were generally greater than expulsion rates for different IUDs;• FHI data show that emphasis needs to be given to the fundal placement of the device.• The provider should be able to feel the device through the abdominal and uterine walls at the time of insertion.• Retraining is necessary for those individuals who report high expulsion rates www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010
    • Teknik Pemasangan AKDRAffandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010
    • Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010
    • Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010
    • Statement , WHO-Geneva , 22 Oct. 2008: Progestin-only contraceptive use during lactation1. Use of progestin-only methods, with the exception of the levonorgestrel bearing IUD, is not usually recommended for women who are less than 6 weeks postpartum and breastfeeding, unless other more appropriate methods are unavailable or unacceptable.2. Beyond 6 weeks postpartum, there is no restriction for the use of progestin only contraceptive methods among breastfeeding women.3. The levonorgestrel-bearing IUD is not usually recommended for the first 4 postpartum weeks, unless other more appropriate methods are unavailable or unacceptable. Beyond 4 weeks postpartum, there is no restriction on its use. Affandi B. Postpartum Contraception & Medical Barrier. Department of Obstetrics & Gynecology , University of Indonesia , Jakarta , 22 Sept. 2010
    • Simplified Classification of Eligibility Criteria (WHO) Affandi B. Perkembangan Kontrasepsi, Teknik Penapisan dan KB Postpartum , BPMPPKB, Balikpapan , 24 Juni 2010
    • Three-pronged strategy to reducing maternal mortality■ Family planning to ensure that every birth is wanted■ Skilled care by a health professional with midwifery skills for every pregnant woman during pregnancy and childbirth■ Emergency Obstetric Care (EmOC) to ensure timely access to care for women experiencing complications. UNFPA , 2009
    • WHAT IS SKILLED ATTENDANCE AT BIRTH?• Skilled attendance refers to professionally trained health workers with the skills necessary to manage a normal delivery and diagnose or refer obstetric complications.• This usually refers to a doctor, midwife or nurse.• Skilled attendants must be able to manage a normal labour and delivery, recognize complications early on and perform any essential interventions, start treatment, and supervise the referral of mother and baby to the next level of care if necessary.• Trained and untrained traditional birth attendants (TBAs) are not included in this category. (WHO/UNFPA/UNICEF/WORLD BANK. JOINT STATEMENT FOR REDUCING MATERNAL MORTALITY, 1999. )
    • Ronsmans et al. Bulletin WHO 2009;87:416-423
    • Ronsmans et al. Bulletin WHO 2009;87:416-423
    • Ronsmans et al. Bulletin WHO 2009;87:416-423
    • Three-pronged strategy to reducing maternal mortality■ Family planning to ensure that every birth is wanted■ Skilled care by a health professional with midwifery skills for every pregnant woman during pregnancy and childbirth■ Emergency Obstetric Care (EmOC) to ensure timely access to care for women experiencing complications. UNFPA , 2009
    • Emergency Neonatology&Obstetrics Care (EmNOC) 1. Parenteral antibiotics 2. Parenteral oxytocics 3. Parenteral anticonvulsants 4. Manual removal of the placenta 5. Removal of retained products 6. Assisted or instrumental Vaginal Delivery 7. Neonatal resuscitation 8. Blood Transfusion 9. Cesarean delivery 1-7=EmNOC Basic (PONED) 1-7+8&9=EmNOC Comprehensive (PONEK) UNFPA, WHO , 2000
    • Standard , what is it ?• Consensus on minimum requirements• Should include directions for quality development• Must be tested in evaluation studies• A matter of specific conduct & intentional planning• Must be clearly defined, meaningful, appropriate, relevant, measurable, achievable & accepted by
    • STANDARDS• Standards of care inform healthcare providers about what is expected of them and what they should do to deliver high quality services at each level of the healthcare system.• Standards specify the continuum of care that is necessary to improve maternal and neonatal outcomes. Johnson RH . 2001
    • • Standards promote quality care, delivered in the most appropriate way, by the most appropriate personnel.• The likelihood of ensuring high quality care is increased when skilled attendants perform their jobs competently and their competence is verified by comparing their performance to evidence-based standards of care.• Standards can empower women and communities, giving them a tool to advocate for improved healthcare. Johnson RH . 2001
    • Reducing Maternal and Neonatal Mortality in five District Hospitals through Best Practices Implementation Package - ComprehensiveEmergency Obstetrics and Neonatal Care (CEONC) National Clinical Training Network of Indonesia February 15, 2008-April 30, 2011 36 Months Adriansz ,G. Presented at the Global Health Conference and ESD Consultation Meeting , Washington DC , USA , 13-17 June 2011
    • Why Comprehensive Emergency Obstetrics and Neonatal Care?• High MMR & NMR in Indonesia• 42%-65% of maternal & neonatal death occurred in hospitals• 80% emergency cases are not stabilized and timely referred• Only 15% of rural and 32% of urban emergency referral cases treated adequately in hospitals• Although CEONC standards are endorsed by the Ministry of Health, only 32% hospitals institutionalized CEONC standards
    • Purpose of Intervention• Utilize CEONC through improving the competency of practitioners• Enable health centers & community midwives to recognize, stabilize, and refer emergency cases in a timely manner• Create emergency communication and services network• Build capacity of the DHO to lead and monitor the hospital-primary health care collaboration• Assess the Improvement Collaborative effect in reducing MMR & NMR in hospital settings
    • Integrated CEONC ImplementationImplementing CEONC in District Referral Hospital • JNPK-ESD was endorsed by MOH-DG of Medical Services to implement CEONC in Tangerang District Hospitals • CEONC was adapted from ALARM (SOGC) and Basic Neonatal Care (HSP-USAID) by Professional Organizations & MOH • Conducted within MOH Health Delivery System and accommodate Local Government Autonomy Regulation in collaboration with Hospital and DHO (Family Health and Service Delivery Section) • The package also included preventive measures
    • Results on Standard of Inputs & Performance Improved Inputs Inputs: Input Before After infrastructures, equipments, & Maternal 62% 90% manpower for providing CEONC Neonatal 67% 90%Improved Performance Performance: management of services, performance & qualityPerformance Before After improvement, and environtmental Maternal 67% 93% support for CEONC Neonatal 62% 88%
    • Results on Output Reduced Midterm Mortality* Mortality Before After Maternal Death 32 in 2998 12 in 3503Maternal Mortality Ratio 800/100,000 300/100,000 Perinatal Death 85 in 2998 49 in 3503Perinatal Mortality Ratio 42/1,000 20/1,000 Reduced Annual Mortality* Mortality 2009 2010 Maternal Death 52 in 5002 20 in 7018Maternal Mortality Ratio 800/100,000 300/100,000 Perinatal Death 122 in 5002 87 in 7018Perinatal Mortality Ratio 30/1,000 16/1,000*MMR and PMR calculated using WHO Conversion Table, Beyond the Numbers, 2004 Midterm: March - August 2009 & Annual: March 2009 - February 2010
    • Lessons Learned• Intervention must be part of and contribute to the National Health Development Program• Do not create new, just fill the gap of existing effective programs which might divert high-cost to cost-effective interventions• The Best Practices Package must be familiar and practiced daily (starting from what already exist and then, improved gradually)• Implement best practices collaboratively and provide objective information on the main goal and benefits of intervention• Obtain good model and results before approaching health organizations or institutions for replication Adriansz ,G. Presented at the Global Health Conference and ESD Consultation Meeting , Washington DC , USA , 13-17 June 2011