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Dr. dr. SHIRLEY I.

MONINGKEY Mkes
Family and community department
FoM Pelita Harapan University

>200 million women become pregnant each year


585,000 women die each year
20 million women develop chronic debilitating illnesses
as a result of pregnancy-related complication
75 million unwanted pregnancies
50 million induced abortions
20 million unsafe abortions (same as above)
600,000 maternal deaths (1 per minute)
1 maternal death = 30 maternal morbidities

3 million neonatal deaths (first week of life)


3 million stillbirths

Annually, 585,000
women die of
pregnancy related
complications
99% in developing
world
~ 1% in developed
countries

Every Minute...

380 women become pregnant


190 women face unplanned or unwanted
pregnancy
110 women experience a pregnancy related
complication
40 women have an unsafe abortion
1 woman dies from a pregnancy-related
complication

50% (5.767) kematian ibu


25% (2.884) kematian ibu
25% (2.883) kematian ibu

Sumber: Laporan rutin KIA, 2010 & koreksi jumlah kematian ibu dg AKI menuru

JUMLAH KEMATIAN IBU DAN PENYEBABNYA


2012 - NOVEMBER 2013

Sumber : Data rutin direktorat Bina

kesehatan Ibu
Sumber
Data : Data Rutin Kesehatan Ibu 2013

Sumber : Data rutin direktorat Bina


kesehatan Ibu

KECENDERUNGAN ANGKA
KEMATIAN BALITA, BAYI DAN
NEONATAL,
1991 -2015
33%
37%

Proporsi kematian neonatal


dibanding kematian balita
meningkat
43%
48
%

50% kematian
(86.111)
25% kematian
(42.845)
25% kematian
(41.313)

Cause of death of Under Five


(0-59 month)

Cause of death of 0-11 Months Infant


Meningtis, 4.5

Unknown
3.7 %

Unknown 5.5 %
Tetanus, 1.5 %

Kongenital
Anomaliies 5.7
%

Meningtis, 5.1 %

Pneumonia, 12.7 %
Neonatal
Problems
46,2 %

Neonatal
Problems 36
%

Kongeni
tal
Anomali
es4.9 %

Pneumonia, 13.2 %

Diarrhea 15
%

Tetanus, 1.7
%

Neonatal problems:
Asphyxia Low Birth Weight - Infection
Sources; Basic Health Survey
2007

Diarrhea
17.2 %

JUMLAH KEMATIAN IBU DAN PENYEBABNYA


2012 - NOVEMBER 2013

Sumber : Data rutin direktorat Bina

kesehatan Ibu
Sumber
Data : Data Rutin Kesehatan Ibu 2013

Sumber : Data rutin direktorat Bina


kesehatan Ibu

KECENDERUNGAN ANGKA
KEMATIAN BALITA, BAYI DAN
NEONATAL,
1991 -2015
33%
37%

Proporsi kematian neonatal


dibanding kematian balita
meningkat
43%
48
%

FAKTA:
Risfaskes 2011 &
data rutin KIA
2011:
70.15% Bidan
tinggal di desa
64.86% Bidan di
Desa yang
mempunyai Kit
BdD mampu GDON:
10.80%,
BdD telah dilatih
APN: 45.63%.
47,4% puskesmas
perawatan mampu
PONED
42,6% puskesmas
PONED tersedia
MgSO4
Studi Banten,
sebab
keterlambatan 474

Ibu
Selama
t

Persalin
an

85% normal

15% perkiraan
komplikasi, tak
dpt diprediksi tp
dapat dicegah

I. Pemanfaatan
penolong
persalinan
terampil di
pelayanan
fasikes Kualitas
Pencegahan

A
AY
BI

III.
Kualitas
pelayan
an di RS
Akses ke RS
tepat waktu

komplikasi
Identifikasi komplikasi
Pertolongan pertama
thd
Komplikasi
&
penstabilan
sebelum
II.Rujukan
rujukan

Efektif

FAKTA:
SP 2010 Litbangkes 2012:
49.7%-75.3% meninggal di RS
pemerintah dan swasta (tgt jenis
komplikasi); 17.1-37.8% di rumah
sendiri
Studi di Banten: 66% terlambat
mencapai fasilitas rujukan

FAKTA:
Risfaskes 2011
21% RS
Pemerintah
Memenuhi
Kriteria Umum
PONEK
52.7% RSU
pemerintah
dengan Dr telah
terlatih PONEK
50.4 % RSU
pemerintah
dengan Bidan
telah terlatih
PONEK
Studi di Banten:
44% terlambat
mendapatkan
pelayanan di RS

Current Approach to Reduction of


Maternal Mortality

25

Three Delays Model


Delay in decision to seek care
Lack of understanding of complications
Acceptance of maternal death
Low status of women
Socio-cultural barriers to seeking care
Delay in reaching care
Mountains, islands, rivers poor organization
Delay in receiving care
Supplies, personnel
Poorly trained personnel with punitive attitude
Finances

26

Good quality maternal


health services are not
universally available and
accessible
> 35% receive no antenatal
care
~ 50% of deliveries
unattended by skilled
provider
~ 70% receive no postpartum
care during 1st 6 weeks following
delivery

27

Historical Review
Traditional birth attendants
Antenatal care
Risk screening
Current Approach
Skilled attendant at delivery

28

The flawed assumption:


Most life-threatening obstetric
complications can be predicted or
prevented

29

Advantages
Community-based
Sought out by women
Low tech
Teaches clean delivery

30

Disadvantages
Technical skills limited
May keep women away from
life-saving interventions due to
false reassurance

Current Approach to
Reduction of Maternal

Health system improvements:


Introduction of system of health facilities
Expansion of midwifery skills
Decreased use of home delivery and delivery by
untrained birth attendants
Spread of family planning

31

Current Approach to
Reduction of Maternal

85% births attended


by trained personnel

Current Approach to Reduction of


Maternal Mortality

32

Conclusion: TBAs are useful in the maternal health


network, but there will not be a substantial
reduction in maternal mortality by TBAs delivering
clinical services alone

33

Current Approach to
Reduction of Maternal
Mortality

Antenatal care clinics started in US, Australia, Scotland


between 19101915
New concept - screening healthy women for signs of
disease
By 1930s large number (1200) ANC clinics opened in
UK
No reduction in maternal mortality
However, widely used as a maternal mortality
reduction strategy in 1980s and early 1990s
Is ANC important? YES!!
Early detection of problems and birth preparation

34

Improvements in
nutrition, sanitation
Maine 1999.

Antenatal
care

Antibiotics, banked blood,


surgical improvements
35

Proper training, range of skills


Assess risk factors
Recognize onset of complications
Observe woman, monitor fetus/infant
Perform essential basic interventions
Refer mother/baby to higher level of care if
complications arise requiring interventions
outside realm of competence
Have patience and empathy

WHO 1999.
36

Disadvantages
Very-poorly predictive
Costly: Removes woman to maternity waiting
homes
If risk-negative, gives false security
Conclusion: Cannot identify those at risk of
maternal mortality every pregnancy is at risk

37

KELEMAHAN
Prediksi sangat buruk
Mahal memberikan keamanan palsu

SEBAGIAN BESAR WANITA YG DIMASUKKAN


KELOMPOK RISIKO TINGGI TIDAK PERNAH
MENGALAMI KOMPLIKASI

Pregnancy is a period of risk


Any pregnant woman can have complication
and die
Accurately predicting which woman will
develop complication is not possible
Early detection and management of
complications is vital

Proven effective
Malaysia: basic maternity services 320 157
Cuba: national priority 118 31
China: facility based childbirth 1500 50

Malaysia vs. Indonesia:


Trained community midwives (2 year) vs. untrained
midwives (4 years)

40

komplikasi

Pengaruh pada ibu

Pengaruh pada bayi

Infeksi saat hamil, STD

Premature onset of labour,


Kehamilan ektopik, PID,
infertilitas

Prematur, infeksi mata,


kebutaan, pneumonia,
stillbirth, sifilis congenital

hepatitis

HPP, gagal liver

Hepatitis

Malaria

Anemia berat, trombosis


serebral

Prematur, IUGR

Unwanted pregnacy,

Unsafe abortion, PID,


perdarahan,infertility

Peningkatan risiko
mrbidits dan mortlitas,
child abuse,neglect

Persalinan tidak bersih

Infeksi, tetanus

Neonatal tetanus, sepsis

Komplikiasi

Pengaruh pada ibu

Pengaruh pada bayi

Anemia berat

Cardiac failure

B BLR, asfiksia, stillbirth

Perdarahan

Shock, c.failure, infeksi

Asfiksia, stillbirth

Hipertensi

Eklampsia, CVA

BBLR. Asfiksi, stillbirth

Sepsis puerpuralis

Septikemia, shock

Sepsis pada neonatus

Partus lama

Fistula, ruptura
uterin,prolaps, amnionitis,
sepsis

Stillbirth, asfiksia, sepsis,


trauma lahir, cacat

Causes of maternal
deaths

Proven intervention

Postpartum
Haemorrhage

Treat anemia
Skilled attendant at birt
Prevent/treat bleeding with
correct drugs
Replace fluid loss/tranfusion

Infection after delivery

Skilled attendant
Clean practise
Antibiotics if infection arises

Causes of maternal deaths

Proven intervention

Hypertension during
pregnancy

Detect in pregnancy
Refer to hospital
Treat eclampsia with appropriate
anticonvulsive
Referunconscious woman

Obstructed labour

Detection in time and referral for


operative surgery

Other direct obstetric causes

Refer ectopic pregnancy for operation

Indirect causes

Disease-specific intervention (malaria,


HIV)

Causes of neonatal deaths

Proven intervention

Infection (septic meningitis,


pneumonia, NT, congenital
syphillis

TT immunization, syphillis
screening and treatment, clean
delivery, early and exclusive
breastfeeding, early recognition
and management

Causes of neonatal deaths

Proven intervention

Birth asphyxia and trauma

Skilled attendant at birth


Effective management of maternal
obstetric complication

Preterm birth and/or low birth weight

Anti-malarials at risk during


pregnancy
Breastfeeding counselling and
support
Infection control
Early detection and m,anagement of
complication
STD treatment
Smoking cessation