State of the World's Midwifery 2014 - Indonesia: Achieving MDG 5

Publication date: 2014

Indonesia Achieving MDG 5 Maternal Mortality With a population of over 248 million in 2013i, Indonesia is the 4th most populous country in the World. It is also among the top ten countries in the world when it comes to maternal mortality. With over 8,500 women dying in pregnancy or childbirth, Indonesia accounts for almost 3% of the global maternal death burdenii. Indonesia has made significant progress in reducing the maternal mortality ratio but at the current trend is not on track to reach the 75% reduction in the MMR required by the MDG5. According to UN data, in 2013 it had a MMR of 190 per 100,000 live birthsiii. A concerted effort will be required to reach the goal of an MMR of 102iiia (or about 4,800 annual deaths) by 2015. Almost 80% of all maternal deaths in Indonesia are due to hemorrhage, eclampsia, sepsis and abortion complicationsiv. An estimated 2,100 of these deaths are among adolescentsv Family Planning and Maternal Health vi,vii,viii,ix In addition to a 75% reduction in the MMR, MDG5 also calls for universal access to reproductive health care by 2015. Indonesia is doing relatively well on this front. The following shows current coverage with key reproductive services in Indonesia. Family Planning 58% of Indonesian women use modern family planning methods, only 11% have an expressed unmet need for family planning (IDHS 2012). Antenatal Care 95.7% of pregnant women had at least 4 antenatal care visits (IDHS 2012). Skilled Delivery Care As measured by the 2012 IDHS survey, 83% of the annual 4.5 million births in Indonesia were assisted by a skilled attendant. Estimated Impact of Universal Access to Reproductive Health Family Planning Providing women with access to family planning and making it possible for them to decide how many children they want and when to have them, reduces the overall number of deaths by reducing the number of women dying due to pregnancies they never intended to have. Meeting only 25% of the unmet demand for family planning in Indonesia, i.e., supplying 1.4 million additional women with access to family planning would reduce the number of unintended pregnancies by 520,000 and deaths related to unintended births and abortions by almost 1,000. Maternal Health Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. The following interventions and drugs tackle the four top causes of maternal deaths in Indonesia:  Prevention and management of hemorrhage/treatment of postabortion complications - Oxytocin  Prevention and management of eclampsia with Magnesium sulfate  Prevention and treatment of sepsis with Clean delivery kits and antibiotics Number of Maternal Deaths that Could be Prevented Providing all women with the required maternal health medicines and supplies would prevent an additional 3,800 deaths, reducing the annual number of deaths to about 3,700 and the MMR to just under 90, making it possible for Indonesia to not only reach, but exceed its MDG goal of 102. In addition, these interventions would have a significant impact on child, and in particular, newborn mortality. Currently Indonesia has about 67,000 neonatal deaths a year. About 13% of these, or 9,000, could be prevented by providing women with the above life- saving interventionsvii. Essential Drug Requirements and Costs Maternal Health Drugs For Universal Coverage Drug and commodity requirements to provide the care detailed above would cost close to $8 million, $4 for additional FP supplies and approximately $4 million for maternal health (detailed calculations are available in Annex 1). Required health system investments Additional investments will be necessary to strengthen countries’ logistics systems and to ensure that health providers (both at facility and community level) know how to administer these drugs. Annex 1. Methodology The following describes the methodology used to arrive at the impact and cost estimates in the factsheet. Maternal Mortality The number of current annual maternal deaths was calculated using the 2013 MMR from the 2014 publication: Trends in Maternal Mortality: 1990-2013. UNFPA, WHO, World Bank, UNICEF http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/ applied to the estimated number of births in 2013 (based on population data from the UN Population Division). Deaths Prevented through Family Planning The number of unintended pregnancies averted was calculated by comparing the number of pregnancies that would have happened if the 1.4 million (25% of the 5.2 million women with currently unmet need in Indonesia) had not been able to access contraception to the number of pregnancies that would occur if these women used contraception (i.e. only experienced pregnancies due to failure of their chosen method). It was assumed that 40% of all women would have gotten pregnant if not using contraception. The average failure rate of contraceptives was estimated to be 3%. Based on regional data collected by the Guttmacher Institute for its 2014 update of “Adding It Up” it was estimated that only about 39% of unintended pregnancies would be carried to term, 49% would be aborted and 13% would end in a miscarriage. Note: Family planning reduces the absolute number of maternal deaths in a country but since it reduces both numerator AND denominator of the Maternal Mortality Ratio (defined as deaths per 100,000 live births) the reduction in maternal deaths caused by family planning is not reflected in the MMR. The estimated reduction in number of deaths required to achieve the country’s MMR goal differs therefore slightly depending on the assumption made about the number of births. The estimate in the first paragraph uses the current number of births, while the estimate in the Estimated Impact paragraph is based on a lower number of births (originally projected number of births minus unintended births averted through the provision of contraception to women with unmet need). Deaths Prevented through Maternal Health Interventions It was assumed that half of the women currently covered by skilled birth attendance, i.e. about 42%, had access to the three live-saving drugs. This coverage was then scaled up to 100%. The following effectiveness data were used in estimating the expected reduction in maternal deaths: Intervention Effectiveness Source 1. Hemorrhage Prevention - Oxytocin 62% Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. In: The Cochrane Library, Issue 1. 2. Hemorrhage Prevention - Misoprostol 43% 30% less effective than oxytocin Gulmezoglu AM, Villar J, Ngoc NTN, et al. WHO multicentre randomized trial of misoprostol in the management of the third stage of labour. Lancet. 2001; 358:689-695 3. Hemorrhage Treatment - Oxytocin 80% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 4. Eclampsia Management - MgSulfate 43% Cochrane Database Syst Rev. 2010 Nov 10 5. Sepsis Prevention - Facility Births 60% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 6. Sepsis Prevention - Home Births 60% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 7. Sepsis treatment - Antibiotics 80% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 8. PAC management - Misoprostol 50% The final MMR was calculated by dividing the remaining number of maternal deaths by the number of births expected at the new contraceptive prevalence level (current 4.5 million births annually minus 170,000 averted through increased use of family planning. Cost Estimates Family Planning Unit costs for the different supply methods were taken from UNFPA’s RH Interchange database and multiplied by the amount required to provide one couple-year of protection (CYP). It was assumed that 15 cycles of the pill, 120 condoms and 4 injectables would provide one CYP. IUDs and Implant were assumed to provide 3.5 years of protection or CYPs. Their cost was thus divided by 3.5. The RHInterchange price for implants ($18.80) was replaced with a cost estimate per implant of $8.50 to reflect the recent price reduction seen, but not yet reflected in the database, due to the introduction of Sino- Implants. Drug and supply cost for male and female sterilization came from calculations carried out by the Guttmacher Institute for its Adding It Up 3 publication using UNFPA’s RHCT costing tool with updated 2013 prices. It was assumed that new users would adopt methods based on the current modern method mix. Cost Estimates Maternal Health Interventions Based on WHO treatment guidelines the following drugs and supplies were costed using drug prices from both the MH International Drug Price Indicator and the UNICEF Supply Catalogue. Hemorrhage Prevention and Treatment Sepsis Prevention and Treatment Pre-Eclampsia/Eclampsia Treatment i Indonesia Population Projection based on Census 2010 data. ii WHO. 2014. Trends in maternal mortality 1990 to 2013: Estimates by WHO, UNICEF, UNFPA, the World Bank and UN Population Division iii WHO. 2014. Trends in maternal mortality 1990 to 2013: Estimates by WHO, UNICEF, UNFPA, the World Bank and UN Population Division Note: There is substantial challenge in measuring MMR in Indonesia. Since 1991, the Indonesian Demographic and Health Survey (IDHS) estimate has been used as a formal national MMR. However, the number of maternal deaths in the sample is small which gives a wide confidence interval, and, therefore, should be carefully interpreted. The latest MMR figure from IDHS 2012 is 359 (a mid point of a range between 239 to 478) per 100,000 live-births. Iiia MMR target as stated in national document "A Roadmap to Accelerate Achievement of the MDGs in Indonesia (National Development Planning Agency/BAPPENAS, 2010) iv Indonesia DHS 2012. v Based on: Blanc et al. 2013. New Findings for Maternal Mortality Age Patterns: Aggregated Results for 38 Countries. PLoS ONE 8(4): e59864. vi Indonesia Population Projection based on Census 2010 data. vii Indonesia DHS 2012. viii Futures Institute. Spectrum, LiST module. ix

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