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Tugas 11 Deaths From Childbirth Dosen Pengampu Dr. Masrul, M.PD
Tugas 11 Deaths From Childbirth Dosen Pengampu Dr. Masrul, M.PD
OLEH:
FITRI NELFAYANTI
NIM:1615301005
byJeanine Barone
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Felicia Lester, MD, is the medical director of gynecologic services at the University of
California, San Francisco. She has an active obstetrics and family planning practice and works
with women who have any of a variety of gynecologic conditions. We spoke with her recently
about why the U.S. ranks at the bottom among developed countries in rates of women dying
during pregnancy, childbirth, or the postpartum period.
How common is it for a woman to die in pregnancy in the U.S., and how does that compare
to other developed countries?
It’s still rare for a woman to die in pregnancy, but it is much higher in the U.S. than it is
in other developed countries. And the rate—which we call the maternal mortality ratio, or MMR
—is increasing in the U.S., whereas it’s declining in most other countries. It’s currently between
17 and 28 per 100,000 live births (depending on source and calculation used), which is more than
double the rate 30 years ago. The MMR includes death of a woman related to or aggravated by
pregnancy while pregnant or within 42 days of the pregnancy ending, whether it’s an abortion,
miscarriage, or a delivery. Some data also includes late maternal deaths, within one year of
delivery if the cause was pregnancy-related. Our rates in the U.S. are still much lower than in
many resource-limited settings—for example, in Uganda, where I’ve worked, the ratio is 343 per
100,000. But the U.S. rate is about triple the rate in the U.K. and Canada, and six times higher
than the rate in Scandinavian countries. And it results in about 700 to 900 women dying every
year in the U.S. from pregnancy-related causes, as well as about 60,000 to 65,000 of what we
call “near misses,” which means women almost dying.
I think there are multiple causes. But we need to think of the system as a whole. And
what we realize about the U.S. compared to other countries is that we have a real lack of
integration of care between maternity care and primary care. A lot of women lack access to
primary care to prevent chronic medical conditions that can contribute to maternal deaths.
Obesity, diabetes, and hypertension, for example, all are conditions that can make pregnancy
more of a danger for women. They can be managed, controlled, and even prevented in the
primary care setting. But our healthcare system is so fractured that a lot of women lack access to
basic primary health care. This is probably one of the major differences between the U.S. and
other developed countries, where there are concerted efforts to address the problem of maternal
mortality from the perspective of providing universal access to health care that can help prevent
and treat chronic conditions. In the U.S., women who lack health insurance are four times more
likely to die of a pregnancy-related complication compared to their insured counterparts. Part of
the impetus behind the Affordable Care Act was to improve access to primary care for more
people, but the latest trends that we’re seeing in the U.S.—that is, moving farther away from
universal accessto health care rather than towards it—are extremely worrisome for worsening
outcomes for moms and, frankly, for babies.
We also don’t have national protocols for conditions that are most likely to kill women in
the peripartum period (the period preceding and following childbirth), such as postpartum
hemorrhage. This is very different from, for example, the U.K., where there is a specific,
publicly available protocol used throughout the country for this complication. And the quality of
care a woman receives in the U.S. can vary a lot depending on the clinic or hospital where she
happens to go. So that probably contributes as well.
Another factor is that we don’t have great database and review systems for looking at
statistics and also drilling down on individual cases, referred to as morbidity and mortality
reviews (M & M’s). Some hospitals and clinics have them, but many don’t. The reporting and
tracking systems we have are not very well supported and are not universally implemented,
though there are national efforts to work on this—to make sure there are accurate statistics and
that there are always M & M’s, so we are constantly learning and improving from past near-
misses or deaths.
Socioeconomic and racial factors also play a role. National statistics show that there are
huge differences in the MMR by socioeconomic status and location. Poor women and rural
women are more likely to die in pregnancy, for example. But there are also racial differences.
Black women are far more likely to die in pregnancy than white women, regardless of
socioeconomic status. Looking at and understanding this is really important as well.
Finally, the rising rate of cesarean sections (C-sections) may be a contributing factor.
Repeated cesarean sections in particular can cause bleeding complications that can be deadly.
Aside from the rising cesarean section rate, I think it’s because women are getting
pregnant when they have other chronic conditions that may or may not be recognized, and we
haven’t been able to effectively provide access to primary care to be able to control those
conditions and effectively plan pregnancy for when they are under control. Things like diabetes,
obesity, and hypertension are all rising in our country, and therefore, many of the complications
these conditions cause in pregnancy and childbirth are also rising. And I think our health care
system is arguably more fractured than it used to be—meaning people don’t have one place or
provider to go for all of their care and often seek care only for problems, not for preventive
purposes. There are efforts underway to make this less so, but access to primary care is a big
problem in our country. If you have or are at risk for a condition such as obesity or hypertension,
and you have good primary health care, hopefully those conditions would be prevented or
improving or at least not getting exacerbated as we get older. And a pregnancy would hopefully
be planned, especially in women with those conditions, so that the medical condition could be
optimized before the pregnancy occurred. We’re not necessarily optimizing the timing of
pregnancies or optimizing access to primary care to have time to get these conditions under
control or improve.
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We also need to recognize that the disparities in maternal mortality—with black women,
regardless of socioeconomic status, dying in much higher rates than white women—means that
our health care system is not meeting the needs of all pregnant women equally, which represents
systemic racism.
Some of the increase in risk could be due to assisted reproductive technology, which I
mentioned earlier—which means that more older women who may have other medical
conditions are getting pregnant. Assisted reproductive technology also leads to increased
pregnancies with multiples (twins and triplets), which have a higher risk of complications in
pregnancy and childbirth.
What are the most common medical reasons for a woman to die in pregnancy or
childbirth?
Globally, the most likely cause is hemorrhage; it accounts for at least a quarter of the
maternal deaths worldwide. But in our country—and I think this goes along with the risk factors
of older moms with obesity, diabetes, and hypertension that I already mentioned—15 percent are
from cardiovascular disease, 11 percent from cardiomyopathy (an enlargement of the heart
muscle), nine percent from pulmonary embolism (a blood clot that travels to the lung), seven
percent from hypertensive disorders—including preeclampsia, and seven percent from stroke.
Eleven percent are from hemorrhage and another 15 percent are from pre-existing non-
cardiovascular conditions, such as kidney disease, hepatitis, or cancer.
Any pre-existing chronic condition increases the likelihood that a woman will experience
a fatal event in pregnancy or childbirth. For example, women with pre-existing hypertension are
at higher risk to have pre-eclampsia or stroke. Women with pre-existing diabetes are more likely
to have ischemic heart disease or renal failure; women with lupus are more likely to have kidney
failure or pulmonary embolism; women who are obese are more likely to have ischemic heart
disease or pulmonary embolism. Obesity is also a risk factor both for poor wound healing, which
can lead to infection. The changes to the cardiovascular system that occur during pregnancy and
childbirth—increased blood volume, increased cardiac output, decreased lung capacity, and after
delivery, a big shift in fluid back to the heart—can cause a collapse when there’s already an
unaddressed medical problem. This can occur during the pregnancy, during delivery, or
postpartum.
There is broad variation of maternal mortality by state, from a low of about six per
100,000 (California, Massachusetts) to a high of almost 41 per 100,000 (District of Columbia).
This is probably due to a combination of things. The quality of care varies so greatly from site to
site and I think partly that lower quality of care can be due to lack of protocols and standardized
care. You might have providers who are not in the hospital when women are delivering; the
nurses call the doctor if something goes wrong, and he or she has to drive in from home. So there
may be a delay in responding to abnormal vital signs, blood loss, and other emergencies. In a
system where people are in-house with all the providers actually in the hospital, that might be
less likely to occur. Also, not all hospitals have adopted or adhere to evidence-based practice
protocols that say, for example, “if the blood pressure is greater than 140 over 90, then the
provider needs to come into the hospital and help the nurses manage it,” or if it’s above a certain
level, then antihypertensive drugs need to be given. There’s also the lack of standardized M &
M’s I mentioned earlier, in which, when there’s a death or a near-miss, we delve down into it, do
a root-cause analysis, and try to determine why that death occurred—and if there are systemic
factors that need to be changed in order to prevent something like that from happening in the
future. One thing we’ve learned over the years regarding complications in medicine in general is
that there’s often a system-level problem. Protocols are put into place to try to prevent those
types of system-level mistakes from occurring and leading to bad outcomes.
There are also policy-level things that contribute to maternal death or help prevent it, and
these vary widely by state.For instance, programs that provide access to highly effective
contraceptive methods and abortion can help pregnancies be planned and desired, which can
decrease rates of maternal death. Some states, like California, have robust programs, while many
others, like Texas (which has a very high maternal mortality ratio 31/100,000), do not.
Can you talk more about the racial difference in maternal mortality in the U.S.? Why are
black women dying at such a high rate during pregnancy and childbirth compared to their
white peers?
The CDC reports the maternal mortality ratio in the U.S. for white women as 12.7 per
100,000; for black women, it’s 43.5 per 100,000. Can you believe that disparity? It’s
unconscionable. And it’s not just about socioeconomic status or educational status or rural/urban
dwelling status. It’s something else. Highly educated African American women of high
socioeconomic status are still more likely to die in childbirth than a white woman, even one of a
lower socioeconomic status. We need to think about our society in general and determine why
this might be. And some people are starting to study this more, which is wonderful. We think
that at least part of it is due to systemic racism in the medical system. On an individual level, we
can think of unconscious bias that providers and staff may have against black women; on a
broader level, this translates to systemic racism in which we consistently devalue, disrespect, and
distrust black women. Women are more reluctant to seek care in a system that treats them this
way, and when they do, they are less likely to get the same quality of care. We think that this,
along with increased stress during pregnancy, can exacerbate conditions that lead to maternal
death and cause delays in getting high-quality medical care to identify and address the problems.
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In California, the Preterm Birth Initiative at UCSF is looking at racial disparities in terms
of rates of preterm birth, but some of the work they are doing also applies to maternal mortality.
And it’s not only in maternal health care that this disparity comes out. It comes out in all sorts of
conditions: Black women are more likely to die of cervical cancer and cardiovascular disease, for
example. But it’s extremely stark in maternal health.
California has tried to be more proactive for a while now. We have a statewide initiative,
the California Maternal Quality Care Collaborative (CMQCC), to look at maternal mortality and
try to decrease it. They also have protocols for many of the conditions that kill women in
childbirth and tools for hospitals to use to reduce maternal death at their sites. There’s been a big
emphasis on hemorrhage and hypertensive disorders, and having protocols and toolkits for those
conditions; they are developing others as well. We use these at my institution and they are being
used at many smaller hospitals throughout California as well. One of the reasons we have high
rates of hemorrhage is because of repeat C-sections. After many C-sections, the placenta is more
likely to implant in the uterus in a dangerous way, called placenta accreta. The placenta implants
into the scar tissue and, when the placenta comes out after the baby is born, the uterus will just
continue to bleed. There is an emphasis on preventing the first cesarean section so as to prevent
this condition from the outset. The CMQCC has been very successful at decreasing maternal
mortality rates in California. It declined by 55 percent between 2006 and 2013, from 16.9 per
100,000 to 7.3, and is now 5.9. The emphasis on effective contraception and access to abortion
has also been important in California.
What are ways to lower the rates of maternal mortality in the U.S.?
On the national level, making sure that women have access to primary health care as well
as pregnancy-related care. Planned pregnancies decrease the risks to moms and babies of closely
spaced pregnancies (which include increased risk of preterm birth, infant mortality, and maternal
mortality), as well as of pregnancies that occur when other health conditions are not effectively
controlled, like diabetes and hypertension. All of these things can help us improve pregnancy-
related outcomes. Having initiatives like the CCMQC on the national level would also help.
There is also the current emphasis on fetal and infant care as opposed to maternal health care that
is important to look at. For example, the Title X Fund (part of the U.S. Public Health Service
Act, a federal program that provides funding for family planning services) spends 6 percent of its
funds on the mom vs. 78 percent on infants and children. Furthermore, Medicaid covers the mom
for 60 days after delivery, but the baby is covered for a full year. If the mother had a chronic
medical condition, she wouldn’t be able to get ongoing care for it. Then suppose three years
later, she gets pregnant again. Not only is she older, but if she hasobesity, diabetes, or
hypertension—and there are a lot of women whohave all three—and has gotten no health care
between pregnancies, her medical conditions have likely worsened. This is an issue that should
be addressed.
The U.S. has a joint commission that accredits health care facilities, and they have a set
of five core values that they look at regarding maternity care in hospitals.Four of those are about
the baby, and only one is about the mom (the C-section rate). So I think having more of an
emphasis on maternal outcomes and not only the infant could help as well. We could also do
better in terms of training for high-risk obstetrics care. There’s a financial incentive for
recognizing fetal conditions. There is a high rate of insurance reimbursement for all the
ultrasounds during pregnancy and hospitals get reimbursed well for babies in the neonatal
intensive care unit. These things are not bad, but we need to think about why we are emphasizing
this rather than maternal health at the same time as we’re seeing higher rates of maternal death.
Finally, we need to recognize and take responsibility for the racial disparities in maternal
mortality and address them head on. This means teaching providers and staff about the dire
consequences of structural racism in healthcare and changing how we provide care to make sure
that all patients feel comfortable seeking care, their concerns are heard and addressed, and high-
quality care is provided to everyone, regardless of race. I think we will be seeing more research
into how to best addressstructural racism to narrow these disparities and reverse the trends that
we see now.
TERJEMAHAN
Dapatkah Anda berbicara lebih banyak tentang perbedaan ras dalam kematian ibu di
AS? Mengapa wanita kulit hitam mati pada tingkat yang tinggi selama kehamilan dan persalinan
dibandingkan dengan rekan-rekan putih mereka?
CDC melaporkan rasio kematian ibu di AS untuk wanita kulit putih sebesar 12,7 per 100.000;
untuk wanita kulit hitam, itu 43,5 per 100.000. Bisakah Anda percaya perbedaan itu? Itu tidak
sopan. Dan itu bukan hanya tentang status sosial ekonomi atau status pendidikan atau status
tinggal di pedesaan / perkotaan. Itu sesuatu yang lain. Perempuan Afrika Amerika yang
berpendidikan tinggi yang berstatus sosial ekonomi tinggi masih lebih mungkin meninggal saat
melahirkan daripada wanita kulit putih, bahkan salah satu dari status sosial ekonomi yang lebih
rendah. Kita perlu memikirkan masyarakat kita secara umum dan menentukan mengapa hal ini
terjadi. Dan beberapa orang mulai mempelajarinya lebih banyak, ini luar biasa. Kami berpikir
bahwa setidaknya sebagian dari itu adalah karena rasisme sistemik dalam sistem medis. Pada
tingkat individu, kita dapat memikirkan bias tidak sadar yang mungkin dialami oleh penyedia
dan staf terhadap perempuan kulit hitam; pada tingkat yang lebih luas, ini diterjemahkan ke
rasisme sistemik di mana kita secara konsisten merendahkan, tidak menghormati, dan tidak
mempercayai perempuan kulit hitam. Wanita lebih enggan untuk mencari perawatan dalam
sistem yang memperlakukan mereka seperti ini, dan ketika mereka melakukannya, mereka
cenderung untuk mendapatkan kualitas perawatan yang sama. Kami berpikir bahwa ini, bersama
dengan peningkatan stres selama kehamilan, dapat memperburuk kondisi yang menyebabkan
kematian ibu dan menyebabkan keterlambatan dalam mendapatkan perawatan medis berkualitas
tinggi untuk mengidentifikasi dan mengatasi masalah.
IKLAN
Di California, Inisiatif Kelahiran Prematur di UCSF sedang mencari perbedaan ras
dalam hal tingkat kelahiran prematur, tetapi beberapa pekerjaan yang mereka lakukan juga
berlaku untuk kematian ibu. Dan itu tidak hanya dalam perawatan kesehatan ibu bahwa
perbedaan ini keluar. Muncul dalam segala macam kondisi: Wanita kulit hitam lebih mungkin
meninggal karena kanker serviks dan penyakit kardiovaskular, misalnya. Tetapi itu sangat
mencolok dalam kesehatan ibu.
Mengapa tingkat kematian ibu menurun di California?
California telah mencoba menjadi lebih proaktif untuk sementara waktu sekarang.
Kami memiliki inisiatif di seluruh negara bagian, California Maternal Quality Care Collaborative
(CMQCC), untuk melihat kematian ibu dan mencoba untuk menurunkannya. Mereka juga
memiliki protokol untuk banyak kondisi yang membunuh wanita saat melahirkan dan alat untuk
rumah sakit digunakan untuk mengurangi kematian ibu di situs mereka. Ada penekanan besar
pada perdarahan dan gangguan hipertensi, serta memiliki protokol dan alat untuk kondisi
tersebut; mereka juga mengembangkan orang lain. Kami menggunakan ini di institusi saya dan
mereka digunakan di banyak rumah sakit yang lebih kecil di seluruh California juga. Salah satu
alasan kami memiliki tingkat perdarahan yang tinggi adalah karena ulangan C-berulang. Setelah
banyak C-section, plasenta lebih mungkin untuk ditanam di rahim dengan cara yang berbahaya,
yang disebut plasenta akreta. Implan plasenta ke dalam jaringan parut dan, ketika plasenta keluar
setelah bayi lahir, rahim akan terus berdarah. Ada penekanan pada pencegahan operasi caesar
pertama untuk mencegah kondisi ini dari awal. CMQCC telah sangat sukses dalam menurunkan
angka kematian ibu di California. Ini menurun sebesar 55 persen antara 2006 dan 2013, dari 16,9
per 100.000 menjadi 7,3, dan sekarang 5,9. Penekanan pada kontrasepsi yang efektif dan akses
ke aborsi juga penting di California.
Apa saja cara untuk menurunkan tingkat kematian ibu di AS?
Di tingkat nasional, memastikan bahwa wanita memiliki akses ke perawatan kesehatan
primer serta perawatan terkait kehamilan. Kehamilan yang direncanakan menurunkan risiko pada
ibu dan bayi dari jarak kehamilan yang dekat (yang termasuk peningkatan risiko kelahiran
prematur, kematian bayi, dan kematian ibu), serta kehamilan yang terjadi ketika kondisi
kesehatan lainnya tidak dikendalikan secara efektif, seperti diabetes dan hipertensi. . Semua hal
ini dapat membantu kami meningkatkan hasil yang berhubungan dengan kehamilan. Memiliki
inisiatif seperti CCMQC di tingkat nasional juga akan membantu. Ada juga penekanan saat ini
pada perawatan janin dan bayi dibandingkan dengan perawatan kesehatan ibu yang penting
untuk dilihat. Misalnya, Dana Judul X (bagian dari Undang-Undang Layanan Kesehatan Publik
A.S., program federal yang menyediakan dana untuk layanan keluarga berencana) menghabiskan
6 persen dari dana untuk ibunya vs. 78 persen untuk bayi dan anak-anak. Selanjutnya, Medicaid
mencakup ibu selama 60 hari setelah melahirkan, tetapi bayinya ditutupi selama setahun penuh.
Jika ibu memiliki kondisi medis yang kronis, dia tidak akan bisa mendapatkan perawatan
berkelanjutan untuk itu. Kemudian kira tiga tahun kemudian, dia hamil lagi. Tidak hanya dia
lebih tua, tetapi jika dia memiliki kegaduhan, diabetes, atau hipertensi — dan ada banyak wanita
yang memiliki ketiga — dan tidak mendapatkan perawatan kesehatan di antara kehamilan,
kondisi medisnya mungkin memburuk. Ini adalah masalah yang harus ditangani.
AS memiliki komisi gabungan yang mengakreditasi fasilitas perawatan kesehatan, dan
mereka memiliki seperangkat lima nilai inti yang mereka lihat mengenai perawatan bersalin di
rumah sakit. Empat diantaranya tentang bayi, dan hanya satu yang tentang ibu (C- tingkat
bagian). Jadi saya pikir memiliki lebih banyak penekanan pada hasil ibu dan tidak hanya bayi
dapat membantu juga. Kami juga dapat melakukan yang lebih baik dalam hal pelatihan untuk
perawatan kebidanan risiko tinggi. Ada insentif keuangan untuk mengenali kondisi janin. Ada
tingkat penggantian asuransi yang tinggi untuk semua ultrasound selama kehamilan dan rumah
sakit mendapatkan penggantian yang baik untuk bayi di unit perawatan intensif neonatal. Hal-hal
ini tidak buruk, tetapi kita perlu memikirkan mengapa kita menekankan hal ini daripada
kesehatan ibu pada saat yang sama ketika kita melihat tingkat kematian ibu yang lebih tinggi.
Akhirnya, kita perlu mengenali dan bertanggung jawab atas perbedaan ras dalam
kematian ibu dan mengatasinya secara langsung. Ini berarti mengajar penyedia dan staf tentang
konsekuensi yang mengerikan dari rasisme struktural dalam perawatan kesehatan dan mengubah
cara kami memberikan perawatan untuk memastikan bahwa semua pasien merasa nyaman
mencari perawatan, kekhawatiran mereka didengar dan ditangani, dan perawatan berkualitas
tinggi diberikan kepada semua orang, terlepas dari apa pun. ras. Saya pikir kita akan melihat
lebih banyak penelitian tentang cara terbaik mengatasi rasisme struktural untuk mempersempit
kesenjangan ini dan membalikkan tren yang kita lihat sekarang.
PENGULANGAN DALAM BAHASA SENDIRI
Setiap kondisi kronis yang sudah ada meningkatkan kemungkinan bahwa seorang
wanita akan mengalami peristiwa fatal dalam kehamilan atau persalinan. Sebagai contoh, wanita
dengan hipertensi yang sudah ada memiliki risiko lebih tinggi untuk mengalami preeklamsia atau
stroke. Wanita dengan diabetes yang sudah ada lebih mungkin untuk memiliki penyakit jantung
iskemik atau gagal ginjal; wanita dengan lupus lebih mungkin mengalami gagal ginjal atau
emboli paru; wanita yang mengalami obesitas lebih mungkin mengalami penyakit jantung
iskemik atau emboli paru.Bukan hanya tentang penyakit tetapi juga dari sitem kerja dan Faktor
lain yang berkontribusi terhadap hasil buruk negara kita adalah kurangnya penekanan pada
kesehatan ibu dibandingkan dengan kesehatan janin. Dulu spesialis dalam kebidanan adalah
spesialis dalam kesehatan ibu, dan mereka benar-benar mengerti dan dapat memberikan
perawatan kritis yang dibutuhkan untuk wanita ketika komplikasi muncul pada kehamilan atau
persalinan. Tapi sekarang banyak program kedokteran ibu-janin kami fokus pada diagnosis janin,
Namun dalam artikel ini membahas kematian bukan karna penyakit kronos-kronis
sperti diatas,melainkan kematian ibu yang diakibatkan oleh perbedaan warna kulit atau ras
lainnya.Seperti yang telah dolaporkan oleh CDC melaporkan rasio kematian ibu di AS untuk
wanita kulit putih sebesar 12,7 per 100.000; untuk wanita kulit hitam, itu 43,5 per 100.000.
Setelah dipelajari begitu dalam ternyata bukan karna perbedaan warna kulit tetapi rasa dan
loyalitas seorang tenaga medis yang tidak mementingkan keberdaan orang kulit hitam atau
kurang nya pelayanan yang diberikan kepada wanita hamil yang berkulit hitam yang ada di
AS.Saya sebagai bidan telah mempelajari ilmu yang mana saya dapatkan sewaktu bangku kuliah
sekarang bahwa tidak ada yang nama nya perbedaan dalam pelayanan meskipun itu bersifat kecil
maupun besar.Medis diajarkan bertindak sesuai dengan SOP bukan dengan STATUS pasien.
Akhirnya, kita perlu mengenali dan bertanggung jawab atas perbedaan ras dalam
kematian ibu dan mengatasinya secara langsung. Ini berarti mengajar penyedia dan staf tentang
konsekuensi yang mengerikan dari rasisme struktural dalam perawatan kesehatan dan mengubah
cara kami memberikan perawatan untuk memastikan bahwa semua pasien merasa nyaman
mencari perawatan, kekhawatiran mereka didengar dan ditangani, dan perawatan berkualitas
tinggi diberikan kepada semua orang, terlepas dari apa pun. Ras bukan lah barometer untuk
seseorang dalam mendapatkan pelayanan kesehatan.Jika lah Ras kita jadikan sebagai barometer
dalam dunia kesehatan tak kan lah pernah terjadi yang nam nya penurunan AKI dan AKB serta
tidak terwujud nya pencapaian derajat kesehatan yang kita inginkan.