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Ada apa dengan AKI di

Indonesia?

Disajikan oleh: Roy Tjiong,


pada Seminar Sehari dalam
rangka memperingati Ultah
PKBI, Wisma PKBI-Jakarta, 23
Desember 2013
AKI: SDKI 1991-2012
TFR: SDKI 1981-2012
Teori Fertility Decline

http://www.geographylwc.org.uk/A/AS/ASpopulation/DTM.htm
Turunnya Angka Kematian
 Revolusi Pertanian yang meningkatkan
produksi Pertanian, sehingga suplai Makanan
meningkat
 Perbaikan Kesehatan Masyarakat yang
“beyond” Pelayanan kesehatan:
– Suplai air bersih dan aman, pengelolaan air limbah,
penata-laksanaan pangan, dan pola hidup bersih
dan sehat
– Pemberdayaan perempuan: melek huruf yang
dikaitkan dengan pendidikan kesehatatan
masyarakat – pola hidup bersih dan sehat
Source: Keith Montgomery THE DEMOGRAPHIC TRANSITION
http://www.uwmc.uwc.edu/geography/demotrans/demtran.htm diakses 3 September 2013
CBR DAN CDR INDONESIA
Total Pop Trend

Source: World Population Prospect, the 2012 Revision, diakses dari


http://esa.un.org/unpd/wpp/unpp/p2k0data.asp tgl 4 sep 2013.
Core of Maternal Death
Study in 5 REGIONS

Determinan Kematian Maternal_kajian Litbangkes


MEDICAL CASES OF MATERNAL
DEATH BASED ON ICD 10 WHO

Region

Cause of maternal death Indonesia

Sumatera Jawa-Bali Kalimantan Sulawesi IBT

Direct obstetric death (O00-


81.5 73.8 80.9 80.2 75.7 77.2
O95)
Indirect obstetric deaths (O98-
18.5 26.2 19.1 19.8 24.3 22.8
O99)

100.0
100.0 100.0 100.0 100.0 100.0
Total (N=888
(N=1738) (N=3333) (N=587) (N=979) (N=7524)
)

Indirect Jawa Bali : Cardiovascular and TB


Indirect IBT : Malaria & TB
Determinan Kematian Maternal_kajian Litbangkes
9

MATERNAL MORTALITY RATE


Region
No of death in month Indonesia
Sumatera Jawa-Bali Kalimantan Sulawesi IBT

No of death in 17 months 1738 3333 587 979 888 7524

No of death in 12 months 1227 2353 414 691 627 5311

No of live birth in 12 months 1.072.588 2.371.448 280.717 345.556 331.845 4.402.154

Uncorrected
Maternal Mortality
114 99 148 200 189 121
Ratio per 100.000
live births

Maternal Mortality
Ratio per 100.000 262 227 340 459 434 278
live births*
*after correction with completeness - divided by 0,4352
Determinan Kematian Maternal_kajian Litbangkes
AGE
CHARACTERISTIC

Legend : 1. Pregnancy with abortive outcome, 2. Edema, proteinuria, and hypertensive disorder (HDK), 3. Placenta previa,
premature separation of placenta and Antepartum hemorrhage, 4. Other maternal care related to fetus and amniotic cavity and
possible delivery problems, 5. Obstructed Labor, 6. Postpartum hemorrhage (PPP), 7. Other complications of pregnant and
delivery, 8. Complication predominantly related puerperium and other conditions

Determinan Kematian Maternal_kajian Litbangkes


11

Saat Meninggal
No Saat meninggal n %
1 Hamil ≤ 20 minggu 543 7.22
2 Hamil > 20 minggu 1372 18.24
3 Persalinan 974 12.95
4 Nifas 4634 61.59
Total 7524 100.00

Kematian Ibu paling sering terjadi dalam tempo 2x24 jam setelah
persalinan, pemantauan pasca persalinan adalah suatu keniscayaan
Determinan Kematian Maternal_kajian Litbangkes
12

Tempat Meninggal

Determinan Kematian Maternal_kajian Litbangkes


Tempat Melahirkan
(SDKI 2002 vs. 2012)

Propinsi Persalinan Nakes Persalinan di rumah


2002 2012 2002 2012
NTB 50.1 81.7 64.2 25.5
NTT 36.4 56.8 85.4 59
Sultra 42 65.9 93 78.3
Sul Sel 62.2 75.8 63.9 52.3
Jatim 80.7 89.8 38.1 15.3

Catatan:
•NTT menerapkan revolusi KIA dan menargetkan pada tahun 2012 melahirkan di
rumah menjadi 30 %, namun SDKI 2012 menunjukkan masih 59% ibu melahirkan di
rumah!
20 Highest Medical Causes
of Maternal Death
Code
NO Rank Causes of death N %
ICD 10
1 O72 Post partum hemorrhage 1533 20.4
2 O15 Eclampsia 1222 16.2
Hypertension and Edema disorders
O10-
3 694 9.2
O13,O16
4 O14 Pre-eclampsia 535 7.1
5 O99.4 Diseases of circulatory system 480 6.4
6 O00-O08 311 4.1
Abortion outcome (abortion, KET, Mola Hidatidosa)
7 O98.0 Tuberculosis 307 4.1
8 O85 Puerperal sepsis 222 2.9
9 O99.5 Diseases of Respiratory System 196 2.6
10 O46 Antepartum Haemorrhage 174 2.3
11 O99.8 Other specific diseases & condition 167 2.2
12 O90.3 Cardio-myopathy in puerperium 126 1.7
13 O32 Mal-presentation of fetus 108 1.4
14 O88 Obstetric embolism 82 1.1
15 O36 Suspect fetal problems 80 1.1
16 O63 Long Labour 77 1
17 O42 Premature ruptur membran 74 1
18 O44 Placenta previa 72 1
19 O45 75 1
Premature separation of placenta(abruptio placenta)
20 O21 Excessive vomiting in pregnancy 66 0.9
Kinerja Yankes
(RISKESDAS 2010)
Region
Kalimanta Indonesia
Sumatera Jawa-Bali Sulawesi IBT
n
MMR 262 227 340 459 434 278
Services Performance (Data Riskesdas 2010)
Who provided ANC
~ Heath Workers (Nakes) 83.2 86.9 79.9 69.6 73.6 83.8
(N=3945334 (N=112935 (N=411173 (N=5674491
(N=883320) (N=321729)
) ) ) )
No of ANC visits (K4)
~ K4 (4 visits) 65.3 77.5 62.0 41.8 63.1 71.5
(N=3388520 (N=222236 (N=4563693
(N=634543) (N=76389) (N=242005)
) ) )
Who attended delivery (Linakes)
~ Health Workers 86.1 80.1 68.5 63.6 67.9 78.6
(N=3587247 (N=363598 (N=5239801
(N=903425) (N=96134) (N=289397)
) ) )
PNC visits (KF1)
~ Visit on day 1-3 71.8 60.6 79.4 85.3 68.9 65.1
(N=530903) (N=2142836) (N=80601) (N=351555) (N=197513) (N=3303408)

Determinan Kematian Maternal_kajian Litbangkes


Kinerja Yan – tatalaksana
Hipertensi Kehamilan
(Riskesdas
Region
2010)
Indonesia
Sumatera Jawa-Bali Kalimantan Sulawesi IBT
MMR due to HDK
87 75 119 149 112 89
(Data PC 2010)
Service Performance (Data Riskesdas 2010)
ANC by
Ÿ Health Workers (Nakes) 81.1 82.8 70.9 73.3 82.8 81.2
(N=67213) (N=329712) (N=13840) (N=42889) (N=31534) (N=485188)
Procedure performed -
ANC
ŸBlood pressure not taken 11.2 6.2 0.0 4.6 8.5 6.7
(N=8663) (N=23809) (N=0) (N=2471) (N=2914) (N=37857)
Ÿ Urine test not done 51.0 49.6 58.9 80.7 55.0 53.3
(N=39339) (N=188931) (N=9166) (N=43632) (N=18941) (N=301009)
Ÿ Blood test not done 70.3 59 74.5 76.9 44.7 61.8
(N=54171) (N=383266) (N=11597) (N=41578) (N=15370) (N=348684)
4 ANC visit (K4)
Ÿ K4 56.1 78.4 44.7 47.5 71.6 71.1
(N=43277) (N=300464) (N=6956) (N=25713) (N=24644) (N=401054)
Delivery attended by (nakes)
Ÿ Health Workers 89.6 80.3 54.6 59.1 78.5 78.5
(N=70805) (N=307849) (N=10664) (N=32683) (N=26857) (N=448858)
PNC visit (KF1)
ŸPNC visit day 1-3 61.4 62.9 86.9 82.6 59.5 65.2
(N=34896) (N=197114) (N=14614) (N=35504) (N=17945) (N=300073)

Determinan Kematian Maternal_kajian Litbangkes


Kinerja Yankes –
penatalaksanaan HPP (Data 17
Riskesdas 2010)
Region
Indonesia
Sumatera Jawa-Bali Kalimantan Sulawesi IBT
MMR due to PPP(Data
43 39 94 119 128 57
SP2010)
Health service performance (Data Riskesdas 2010)
Who conducted ANC (K1)
Ÿ Health Workers 83.7 85.0 79.1 69.6 81.5 82.8
(N=10310
(N=22591) (N=132121) (N=6540) (N=17218) (N=188780)
)
Procedures performed
Ÿ No blood pressure taken 6.4 7.6 0.0 0.0 4.4 6.2
(N=1716) (N=11732) (N=0) (N=0) (N=551) (N=13999)
Ÿ No urine test done 47.9 50.7 46.5 80.4 49.8 53.0
(N=12936) (N=78543) (N=3846) (N=17353) (N=6303) (N=118981)
Ÿ No blood test done 73.1 60.3 70.5 74.6 35.9 62.2
(N=19718) (N=93348) (N=5831) (N=16095) (N=4535) (N=139527)
ANC visit (K4)
Ÿ K4 56.5 74.5 54.0 46.2 73.2 68.8
(N=15248) (N=115390) (N=4465) (N=9977) (N=9252) (N=154332)
Who attended delivery
Ÿ Health Workers 96.5 88.5 65.6 61.8 92.0 86
(N=10926
(N=24080) (N=129727) (N=5426) (N=13622) (N=183781)
)
PNC visit (KF1)
Ÿ PNC visit day 1-3 76.1 67.3 80.5 89.8 44.1 70.1
(N=16151) (N=90656) (N=6068) (N=19763) (N=4488) (N=137126)

Determinan Kematian Maternal_kajian Litbangkes


Perdarahan Pasca
Persalinan (PPP) 18
tertinggi di kawasan
IBT
Konsep :
PPP adalah kondisi gawat darurat yang perlu tindakan segera, acapkali
perlu transfusi, dalam kondisi akut transfusi perlu dilakukan dalam 1 jam
Analisis:
Kasus PPP yang ditolong nakes tertinggi di IBT (81%), dan pada umumnya
kematian terjadi di rumah
Kesimpulan :
Persalinan sudah ditolong oleh nakes, namun tempat persalinan masih
belum di fasyankes
Agenda Aksi:
-Tingkatkan kompetensi nakes
-Tingkatkan persalinan di fasyankes
-Layanan transfusi adalah mutlak untuk mendukung PONED & PONEK

Catatan: Regulasi suplai darah perlu dibuat lebih mendukung penurunan


AKI
Determinan Kematian Maternal_kajian Litbangkes
Kota dengan minimal 4 19
Puskesmas PONED

(87%)

Determinan Kematian Maternal_kajian Litbangkes


District with at least 4 PONED
Puskesmas

(60.5%)

Determinan Kematian Maternal_kajian Litbangkes


PUSKESMAS PONED
KABUPATEN/KOTA

Determinan Kematian Maternal_kajian Litbangkes


22

Puskesmas PONED & Tatalaksana Eklampsia


(Data Rifaskes 2011)

Region

Indonesia
Sumatera Jawa-Bali Kalimantan Sulawesi IBT

Number of 390 709 132 238 205 1674


PONED PUSKMS
MgSO4 20% 35% 46% 44% 35% 23% 42%

MgSO4 40% 34% 51% 46% 39% 24% 47%

Vacuum extraction 54% 54% 46% 48% 39% 52%

Determinan Kematian Maternal_kajian Litbangkes


23

9 KRITERIA PONEK
 Ketersedian kamar operasi yang siap 24 jam untuk
kepentingan gawat darurat obstetrik & neonatal
(PONEK)
 Ketersediaan kamar bersalin yang terhubung dengan
kamar operasi dalam 30 menit
 Tersedia tim medis yang siap untuk melaksankan
tindakan gawat darurat obstetrik
 Ketersediaan layanan transfusi darah selama 24 jam
dalam sehari
 Dukungan staf umum pada PONEK
 Laboratorium siap selama 24 jam dalam sehari
 Radiologi siap selama 24 dalam sehari
 Ruang pemulihan siap selama 24 jam dalam sehari
 Ketersediaan obat dan
Determinan Kematian alat kesehatan
Maternal_kajian Litbangkes
24

SITUATION OF PUBLIC PONEK HOSPITALS


(Data Rifaskes 2011)

Determinan Kematian Maternal_kajian Litbangkes


25

RS Pemerintah yang memenuhi


9 KRITERIA PONEK (%)

Determinan Kematian Maternal_kajian Litbangkes


26

Kematian Ibu akibat Eklampsia

Determinan Kematian Maternal_kajian Litbangkes


27

Kematian Ibu diakibatkan oleh Perdarahan


Pasca Persalinan (PPP)

Determinan Kematian Maternal_kajian Litbangkes


n
MMR 262 227 340 459 434 278
28
RATE OF CAUSES OF MATERNAL DEATH
1. Hypertension in pregnancy 38 33 52 65 49 39
(HDK)
2. Post partum hemorrhage 19 17 41 52 56 25
(PPP)
3. Other causes 32 34 40 48 56 37
DETERMINANTS OF MATERNAL DEATH
ACCESS
1. Delivery with Health 86,1 80,1 68,5 63,6 67,9 78,6
Workers
2. K4 (ANC) 63,3 77,5 62,0 41,8 63,1 71,9
Quality
PONED:
% municipalities with 4 6,0 17,0 - 36,0 11,0 -
PONED Puskesmas (of 34 (of 35 (of 11 (of 9
cities) cities) cities) cities)
% district with 4 PONED 55,0 75,0 54,0 66,0 42,0 -
Puskesmas (of 117 (of 92 dist) (of 46 (of 61 dist) (of 82
dist) dist) dist)
Number of PONED Puskesmas 390 709 132 238 205 1674
PONEK:
18/1 theater
24 hours operating 69,7 81,1 67,6 62,2 62,5 -
2/20
24 hours Surgery Team 70,2 84,1 63,5 45,6 62,5 -
Blood supply 12 50,5 63,1 56,8 46,7 43,8 -
29

PARITAS – Jumlah Persalinan


Mothers
Underlying cause of maternal death
characteristic Total
s 1*
2 *
3 *
4 *
5 *
6 *
7 *
8*

No of children

100.0
1-2 4.4 31.2 3.4 1.6 0.8 18 7.3 33.2 (N=4138)

100.0
3-4 3.8 35.1 2.8 1.4 0.5 23 6.6 26.8 (N=2136)

100.0
>4 4 30.5 3.6 2.2 1.3 25.2 7.3 26 (N=1103)

Legend : 1. Pregnancy with abortive outcome, 2. Oedema, proteinuria, and hypertensive disorder
(HDK), 3. Placenta previa, premature separation of placenta and Antepartum haemorrhage, 4. Other
maternal care related to fetus and amniotic cavity and possible delivery problems, 5. Obstructed
Labour, 6. Postpartum haemorrhage (PPP), 7. Other complications of pregnanct and delivery, 8.
Complication predominantly related puerperium and other conditions
Determinan Kematian Maternal_kajian Litbangkes
30

PENDIDIKAN IBU
Mothers
Underlying cause of maternal death
Total
characteristics 1* 2* 3* 4* 5* 6* 7* 8*
Educational level
No
schooling/P 100.0
3.4 29.4 3.5 1.3 1 25.4 6.9 29.1
rimary (N=3604)
compl
Secondary / 100.0
4.9 34.9 3.4 1.9 0.5 15.9 7.3 31.1
high school (N=500)
100.0
Tertiary 3.4 34.1 0.8 1 1.6 17.4 8 33.7 (N=2740
)

Legend : 1. Pregnancy with abortive outcome, 2. Oedema, proteinuria, and hypertensive disorder
(HDK), 3. Placenta previa, premature separation of placenta and Antepartum haemorrhage, 4. Other
maternal care related to fetus and amniotic cavity and possible delivery problems, 5. Obstructed
Labour, 6. Postpartum haemorrhage (PPP), 7. Other complications of pregnanct and delivery, 8.
Complication predominantly related puerperium and other conditions
Determinan Kematian Maternal_kajian Litbangkes
31

Penyebab Kematian
(Perkotaan vs Perdesaan)
Underlying cause of maternal death
Mother
characteristics Total
1* 2* 3* 4* 5* 6* 7* 8*

100.0
Urban 4.6 36.2 3.6 1.5 0.8 14.3 6.6 32.5 (N=2740)

100.0
Rural 3.9 30.2 3.1 1.7 0.8 23.8 7.4 29.1 (N=4784)

Legend : 1. Pregnancy with abortive outcome, 2. Oedema, proteinuria, and hypertensive disorder
(HDK), 3. Placenta previa, premature separation of placenta and Antepartum haemorrhage, 4.
Other maternal care related to fetus and amniotic cavity and possible delivery problems, 5.
Obstructed Labour, 6. Postpartum haemorrhage (PPP), 7. Other complications of pregnanct and
delivery, 8. Complication predominantly related puerperium and other conditions

Determinan Kematian Maternal_kajian Litbangkes


Kematian Ibu (definisi)
 adalah kematian perempuan selama
kehamilan atau dalam waktu 42 hari
setelah pengakhiran kehamilan,
terlepas dari lama dan tempat
kehamilan, dapat disebabkan oleh
berbagai hal yang mempersulit
penatalaksanaan kehamilan, namun
tidak termasuk kecelakaan
For every 1000
births, who spend
more
RESOURCES Government Households
- providers 10 – 20 2000 - 4000
- Funds/year Small Fraction ALL Resources
- Preventive skills High Low
- Curative skills High Low
PRACTICES
- Hours/day ~8 24
- Days/week ~5 7
VALUES
- Motivation Low High
35

KESIMPULAN
 Penyebab AKI langsung adalah 77,2% dan
tidak langsung adalah 22,8%
 Penyebab tidak langsung di Jawa Bali dan
IBT lebih tinggi dari daerah lain. Penyakit
kardiovaskuler dan TB di Jawa Bali, dan TB
+ Malaria di IBT
 Penyebab langsung yang tertinggi adalah:
eklampsia (32,4%) dan perdarahan pasca
persalinan atau PPP (20,3%)
36

KESIMPULAN

 Terdapat korelasi positif antara tingginya


MMR (Sensus 2010) dan rendahnya
kinerja fasyankes: kompetensi SDM,
ketersediaan obat dan peralatan
kesehatan (Risfaskes 2011)
37

Agenda Aksi
 Turunkan kesenjangan aksesibilitas dan
kualitas fasyankes KIA
 Pada kondisi fasilitas yang minimal, maka
diperlukan improving collaboration
 Cegah kehamilan risiko tinggi: < 20 tahun
(kehamilan remaja) dan usia di atas 35
tahun
 Pemberdayaan perempuan yang dikaitkan
dengan PHBS dan intervensi kesehatan
masyarakat adalah keniscayaan.
38

Agenda Aksi

Case Fatality Rates PPP dan Eklampsia masih


sangat tinggi, perlu dikembangkan upaya
preventif dan promotif, yang mencakup:
Tingkatkan kompetensi pemeriksaan tekanan
darah, urin dan sampel darah petugas kesehatan
(bidan) di Puskesmas, tingkatkan kapasitas
laboratorium puskesmas
Kuratif:
 Ketersediaan obat dan suplai untuk penatalaksanaan
Eklampsia (MgSO4) di Puskesmas dan RS Kabupaten
 Tingkatakan akses pada layanan transfusi darah
 Sediakan vacum extractor
Post MDG: Five
Principles
1. Leave No One Behind.
2. Put Sustainable Development at the Core
3. Transform Economies for Jobs and Inclusive
Growth.
4. Build Peace and Effective, Open and
Accountable Institutions for All.
5. Forge a New Global Partnership.
40
Assessment of the quality of
care for mothers and
newborns in health facilities in
Indonesia
19 February - 3 March 2012
Authors

Dwiana Ocviyanti MD1,2, Sabarinah Prasetyo PhD 3, Asri Adisasmita PhD 3, Prof. Endy Moegni MD 1,2, Imran
Pambudi MD 4, Laurensia Lawintono MSc 5, Lhuri Dwianti Rahmartani MD 1,2, Allan Taufiq Rivai MD 1,2,
Samuel Josafat Olam MD 1,2, Noviyanti Rosmaniar 3 , Fitra Yelda M. Epid 3, RUSTINI FLORANITA 6, MARTIN W.
WEBER Dr. med. habil. 6 and the Indonesian Maternal and Neonatal Quality of Care Assessment Group
Affiliations

1. University of Indonesia, Faculty of Medicine, Jakarta, Indonesia

2. Indonesian Society of Social Obstetrics and Gynaecology

3. University of Indonesia, Faculty of Public Health, Depok, Indonesia

4. Ministry of Health, Jakarta, Indonesia

5. Indonesian Midwives Association

6. World Health Organization, Indonesia country office, Jakarta, Indonesia

Country Caucus Meeting @Women Deliver Conference, 29 May 2013 Kuala Lumpur
Background
 From 1992 to 2010, percentage of skilled birth
attendance increased from 41% to 82% in
Indonesia
 Maternal and infant mortality remain high in
Indonesia:
– Maternal mortality ratio = 228/100,000 live births,
– Infant mortality ratio = 31/1,000 live births
– Neonatal mortality ratio = 19/1,000 live births
 Observations, anecdotes and small scale
studies indicated that the quality of care is
often low.
Methods Assessors:
•20 obstetricians
Data collection Sampled health •20 physicians
period: facilities: •20 midwives
19 Feb – 3 Mar •20 hospitals •20 MoH staffs
2012 •40 health centers •20 UN agency
•40 midwifery clinics staffs
How to assess quality of
care for mothers and
newborn in Indonesia?
 Based on international
standards (e.g. WHO IMPAC
guidelines) and national
standards (e.g. Maternal
health pocket book, CEONC,
BEONC, and Baby friendly
hospital standards)
 Problem oriented: all main
areas assessed
 Action oriented : identification
of areas most in need for
improvement and of action
plan
 Participatory: involvement of
health professionals (and
users) in the assessment
Assessment tools on quality of care for mothers and
newborns in Indonesia

information from 4 main sources:


 visit to facilities
 examination of clinical records
 direct case observation
 interview with staff and with mothers.
The tool is aimed to:
•aid MoH to carry out assessments of MNH care provided at facility
level,
•contribute to the identification of key areas of pregnancy, childbirth and
newborn care that need to be improved.
Scoring: A, B, C
Method: O bservation, I nterview, R ecord

The score is calculated by giving


every A answer 2 points, B answer 1
point, and C answer 0 point. The total
Characteristics of Health
Facilities
Health Centers
Background Characteristics Hospitals (n=20)
(n=40)
Classified as providing
emergency obstetric and 14 (70%) 25 (62,5%)
neonatal care
B 5 (25%) -
Hospital Type/Class   C 8 (40%) -
D 7 (35%) -
Median
Number of Physician
(min- 16 (3-80) 2 (1-6)
max)
Median
Number of Midwives (min- 32 (7-72) 14 (3-19)
max)
0 2 (10%) -
Number of Obstetricians
1 8 (40%) -
>1 10 (50%) -
Median
Number (min- 308 (34–1793) 43 (0 – 541)
of deliveries per year max)
Availability of Essential Drugs &
Supplies in Delivery Room
Summary Score of Quality on
Antenatal Care, Normal
Delivery Care, and Postnatal
Care

Antenatal care
Normal care
delivery
Postnatal care
Main weakness in quality of
antenatal care

<60 60-80 > 80


Main weakness in quality of
normal delivery care
Hospitals Health Centers Midwifery Clinics
 incomplete  incomplete  poor utilization of
medical record medical record partograph
 lack of  lack of competency  midwives can’t
competency of of the health performed the
health provider provider newborn
 poor utilization  poor utilization of resuscitations
of partograph partograph  outdated knowledge
 poor infection  poor infection on normal delivery
control control and emergency
 instruments not obstetric care
sterilized  
 equipment set not
<60 > 80
60-80 available
Main weakness in quality of
postpartum care

Hospitals Health Centers Midwifery Clinics


 incomplete medical  incomplete medical  incomplete medical
record record record
 poor infrastructure  no rooming-in  poor knowledge of
 poor counseling and  information on midwife on postpartum
health education exclusive care
 poor infection breastfeeding was not  routine monitoring of
control given to mothers mother and newborn
 routine newborn  routine newborn baby not meeting the
immunization (polio immunization (polio standard
and hepatitis B) not and hepatitis B) not  polio immunization not
offered offered offered
 routine postpartum  postpartum hemoglobin
monitoring was not level test was not
according to the routinely performed
standard of care  exclusive breast feeding
<60 60-80   > 80 is still not well promoted
and formula milk is still
given
Summary Score of Quality of
Management of Complications in
Hospital

/ r r o r n
m ge ia v e c y bo b a
u
rt ha ps f e in an l a la r e
a
tp orr m m n g n ed s a
s a
l ia rtu d i e g r m g e on
Po aem c
e ps pa e p r t e o n C a t i
H -
e m st e
l ly r e ol e c
r
P cla B r P P r s
o a
Main weakness in
management of
complications at hospital
level (1)
Weakness:
PPH Incomplete medical record
Lack of competencies of
health provider in shock
management
Incomplete lab test
Eclampsia-preeclampsia Irrational use of antibiotics
Poor diagnosis and
management of shock cases
Poor counseling on post

Postpartum fever abortion contraception


No standard operating
procedures

<60 60-80 > 80


management of
complications at hospital
level (2)
<60 60-80 > 80
Bleeding in early pregnancy Weakness:
Incomplete medical record
Lack of competencies of health
provider in shock management
C-Section Incomplete lab test
Irrational use of antibiotics
Poor diagnosis and management

Prolonged labor of shock cases


Poor counseling on post abortion
contraception
No standard operating procedures
C-Section
Inappropriate use of tocolytics
Lack of monitoring
Quality and main weakness of early
recognition of complications in health
centre and midwifery clinics level
Weakness:
No standard operating
Low competencies of
health staff in early
recognition of
management of
complications
Poor infrastructure,
laboratory test, and
medical equipment
Unavailability of essential
drugs e.g. misoprostol
Poor utilization of
partograph
<60 60-80 > 80
Electricity was shut down for 15 minutes in the middle of Caesarean section
(district’s hospital)
Routine Newborn
Care
Neonatal
Resuscitation
Health Center, and
Midwifery Clinics (7 of 10
points)
Summary
 The assessment moved beyond usual
administrative approaches.
 A large number of health professionals trained
in the assessment methodology.
 The assessment gives an insight to the quality
of maternal and neonatal care nationally and
serves as a basis for future improvement
 The assessment of quality is in its nature
somehow subjective.
Conclusion

 Deviations from the accepted quality of care


were documented which need addressing by
administrative processes, financing and
quality improvement processes.
 Quality of maternal and neonatal care is a
global problem.
 Countries need to work together in the
improvement of the quality of care and learn
from each other
Thank You!
WHO, UNICEF, UNFPA,
USAID, UI
Indonesian Obstetric and
Gynaecology Association

Ministry of Health RI

Indonesian Midwives
Association

Medical Doctor,
University of Indonesia