profbiranroadtomaternaldeathpelatihanponekjakarta290812-121128235139-phpapp02

8/12/2019 profbiranroadtomaternaldeathpelatihanponekjakarta290812-121128235139-phpapp02

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THE ROAD TOMATERNAL DEATH

Biran Affandi

Klinik Raden Saleh

Department of Obstetrics and GynecologyFaculty of Medicine , University of Indonesia /

Cipto Mangunkusumo General Hospital

JakartaAffandi B. The Road to Maternal Death . POKJANAS PONE , Jakarta , 29 August 2012


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OBJECTIVES1. To overview Millennium

Development Goals

2. To review Status of Maternal &Neonatal Health in Indonesia

3. To discuss ways in ImprovingMaternal Health in Indonesia

Affandi B. The Road to Maternal Death . POKJANAS PONE , Makassar 19 Juli 2011


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MELLINIUM DEVELOPMENT GOALS(MDGs)

Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011


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GOAL 4: Reduce child mortality

Family planning saves infant lives.Spacing births and limiting

unintended births increases child

survival.Currently, 2.7 million infant deaths

are averted each year by theprevention of unintended

pregnancies.Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011


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PROGRESS INDONESIA (4/8)4. Menurunkan Angka Kematian Anakmenjadi 1/3-nya (2015)

Tantangan:

-Sebab kematian pada anak (ISPA, komplikasi perinatal, &

diare)

-Kesehatan neonatal & maternal

-Perlindungan & Pelayanan Kesehatan

-Penerapan desentralisasi kesehatan


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MDG 5: Improve maternal health

Target 5a: Reduce the maternal mortality ratio by (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 healthby 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 planning

Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011


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PROGRESS INDONESIA (5/8)5. Meningkatkan Kesehatan Ibumenurunkan angka kematian -nya

Tantangan:-Struktur penduduk proporsi wanita subur tinggi meningkatkan kebutuhan lynn

kesehatan

-Penerapan desentralisasi kesehatan

-Keterbatasan biaya & tenaga


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Persalinan 1 tahun terakhir oleh Nakes menurut Provinsi 2010

11Sumber: Riskesdas 2010


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Proporsi Persalinan menurut Tempat Melahirkan

55.4

1.4

43.2

0.010.0

20.0

30.0

40.0

50.0

60.0

70.0

Fasilitas kesehatan Polindes/Poskesdes Rumah/Lainnya

Persen

Tempat Melahirkan

Sumber : Riskesdas 2010

12

51,9% persalinan ditolong bidan 40,2% ditolong dukun


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Kesenjangan Pelayanan AntenatalK1 & K4

0

20

40

60

80

100

K1 K4

92.8

61.3

13Sumber: Riskesdas 2010


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Of the 11 countries that contribute to 65

percent to global maternal death, five are in

Asian countries includingIndonesia, Bangladesh, Pakistan , India and

Afghanistan.

A high maternal mortality rate is anindicator of the status of poor functioning of

a countrys health system including lack of

supportive and protective legal and policyenvironment.

Dr. S.T.Mathai, UNFPA , The Jakarta Post , 13 Jan. , 2010

Affandi B. Kesehatan Reproduksi dan Upaya Kesehatan Maternal di Indonesia , Quo Vadis ? Orasi pada PIT XVIII-POGI , Jakarta , 7 Juli 2010


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Women's status As measured by indicators such as level of

education relative to men, age at firstmarriage, and reproductive autonomy, is a strongpredictor of maternal mortality.

Economic dependency, especially multinational

corporate investment, has a detrimental effect onmaternal mortality that is mediated by its harmfulimpacts on economic growth and the status ofwomen.

Support for developmental theory, a variant ofmodernization theory. Shen & Williamson . Soc Sci Med. 1999, 49:197-214


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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 ensuretimely access to care for women experiencing

complications. UNFPA , 2009


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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


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0.00

25.00

50.00

75.00

100.00

125.00

150.00

175.00

200.00

225.00

1600 1700 1800 1900 2000

205 m

18.314.210.8

40.2

250.00

275.00

300.00

285 million

FAMILY PLANNINGREDUCED8 MILLION

POPULATION IN INDONESIA(Million)

FAMILY PLANNINGREDUCED1 MILLION

330 million

230 m

2009



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CONTRACEPTIVE PREVALENCE

INDONESIA , 1970-2007

0

10

20

30

40

50

60

70

80

1970 1980 1987 1997 2002 2007

26 %

5 % (?)

48 %

57 %60 % 61.4 %



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PERENCANAAN KELUARGA

1. Seorang wanita telah dapat melahirkan, segera

setelah ia mendapat haid yang pertama(menarche)

2. Kesuburan seorang wanita akan terusberlangsung, sampai mati haid (menopause)

3. Kehamilan dan kelahiran yang terbaik, artinyarisiko paling rendah untuk ibu dan anak, adalahantara 20-35 tahun

4. Persalinan pertama dan kedua paling rendahrisikonya

5. Jarak antara dua kelahiran sebaiknya 2-4 tahun

Affandi, 1984


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POLA PERENCANAAN KELUARGA

2 - 4

20 35

Fase Fase Fase

Menunda

Kehamilan

Menjarangkan

KehamilanTidak Hamil

lagi

Affandi, 1984


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CONTRACEPTIVE METHODS

RATIONALE CHOICE

2 - 4

20 35

Phase

DIFFERING SPACING COMPLETING

- Pill

- IUD- Conventional

- Inject.

- Implant

- IUD

- Inject.- Pill

- Implant

- Conventional

- IUD

- Inject.- Pill

- Implant

- Conventional

- Steril

- Steril

- IUD- Pill

- Implant

- Inject.

- Conventional

Phase Phase

Affandi, 1984


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BIRTH RATE

STILL HIGH ! ! !

4.5 5 Million/year



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FAKTA

1.Pascasalin OVULASI dapatterjadi dalam waktu 21 hari

2.Pascakeguguran OVULASI

dapat TERJADI dalam waktu

11hari

Affandi B. Kontrasepsi Terkini dan IUD Pascaplasenta . Pertemuan Koordinasi Peningkatan KB Pascapersalinan di Rumah Sakit , Makassar 31 Agustus 2010

Contraceptive choices for breastfeeding women .Journal of Family Planning and Reproductive Health Care 2004; 30(3): 181189


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IUD-Cu

Affandi B. Perkembangan Kontrasepsi, Teknik Penapisan dan KB Postpartum , BPMPPKB, Balikpapan , 24 Juni 2010


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The postpartum insertion of IUDs has

a number of advantages, including

ease of insertion, availability of skilledpersonnel and appropriate

facilities, and convenience for thewoman.

Practitioners have been concerned

about the possibility of higher

expulsion, infection and perforation

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


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Postplacental (preferably within

10 minutes after expulsion of theplacenta) and immediatepostpartum insertion during thefirst week after delivery (butpreferably within 48 hours) are

convenient effective and safetimes to insert copper IUDs.


{Managing Contraception 2005-2007, page 92}


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d l l


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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 thanexpulsion rates for different IUDs;

FHI data show that emphasis needs to be given to thefundal placement of the device.

The provider should be able to feel the device through

the abdominal and uterine walls at the time ofinsertion.

Retraining is necessary for those individuals whoreport high expulsion rates www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm


T k ik P AKDR


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Teknik Pemasangan AKDR



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Statement , WHO-Geneva , 22 Oct. 2008:Progestin-only contraceptive use during lactation

1. Use of progestin-only methods, with the exception of thelevonorgestrel bearing IUD, is not usually recommended forwomen who are less than 6 weeks postpartum andbreastfeeding, unless other more appropriate methods areunavailable or unacceptable.

2. Beyond 6 weeks postpartum, there is no restriction for the use ofprogestin only contraceptive methods among breastfeedingwomen.

3. The levonorgestrel-bearing IUD is not usually recommended for

the first 4 postpartum weeks, unless other more appropriatemethods are unavailable or unacceptable. Beyond 4 weekspostpartum, there is no restriction on its use.



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Simplified Classification of Eligibility

Criteria (WHO)



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Th d t t


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wanted




Emergency Obstetric Care (EmOC) to ensure

timely access to care for women experiencing



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WHAT IS SKILLED ATTENDANCE AT BIRTH? Skilled attendance refers to professionally trained

health workers with the skills necessary to managea normal delivery and diagnose or refer obstetriccomplications.

This usually refers to a doctor, midwife or nurse.

Skilled attendants must be able to manage a normallabour and delivery, recognize complications earlyon and perform any essential interventions, starttreatment, 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. )


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Ronsmans et al. Bulletin WHO 2009;87:416-423


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Th d t t


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wanted




Emergency Obstetric Care (EmOC) to ensure

timely access to care for women experiencing


E N l &Ob i C


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Emergency Neonatology&Obstetrics Care

(EmNOC)

1. Parenteral antibiotics2. 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 Transfusion9. Cesarean delivery

1-7=EmNOC Basic (PONED)

1-7+8&9=EmNOC Comprehensive (PONEK)UNFPA, WHO , 2000

Standard what is it ?


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Standard , what is it ? Consensus on minimum requirements

Should include directions for qualitydevelopment

Must be tested in evaluation studies A matter of specific conduct & intentional

planning

Must be clearlydefined, meaningful, appropriate, relevant,

measurable, achievable & accepted by

STANDARDS


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STANDARDS

Standards of care inform healthcareproviders about what is expected of

them and what they should do to

deliver high quality services at eachlevel of the healthcare system.

Standards specify the continuum ofcare that is necessary to improve

maternal and neonatal outcomes.Johnson RH . 2001


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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 competenceis 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


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Reducing Maternal and Neonatal Mortality in five

District Hospitals through Best PracticesImplementation Package - Comprehensive

Emergency 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

h h b


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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 timelyreferred

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

P f I t ti


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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


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Integrated CEONC ImplementationImplementing CEONC in District Referral Hospital

JNPK-ESD was endorsed by MOH-DG of Medical Services toimplement 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 andaccommodate Local Government Autonomy Regulation incollaboration with Hospital and DHO (Family Health andService Delivery Section)

The package also included preventive measures

R l S d d f I & P f


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Results on Standard of Inputs & Performance

Improved InputsInput Before After

Maternal 62% 90%

Neonatal 67% 90%

Improved Performance

Performance Before After

Maternal 67% 93%Neonatal 62% 88%

Inputs:infrastructures, equipments, &

manpower for providing CEONC

Performance: management of

services, performance & quality

improvement, and environtmental

support for CEONC


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Lessons Learned


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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

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