Kebijakan & Strategi MCH di Indonesia Titik Kuntari Departemen Ilmu Kesehatan Masyarakat FK UII
Kematian Maternal? • =kematian yang dialami seorang perempuan yang sedang hamil atau dalam 42 hari setelah terminasi kehamilan, oleh sebab- sebab terkait kehamilan atau manajemennya tetapi bukan karena kecelakaan (WHO, 2010)
MDGs
PR
• Menurunkan AKB menjadi 2/3 nya pada tahun 2015. 32 kematian per 1000 kelahiran hidup pada tahun 2015. • Menurunkan AKI sebesar ¾ nya antara tahun 1990 dan 2015,97 kematian per 1000 kelahiran hidup.
Menurunkan AKI • Target menjadi ¾ dari AKI tahun 1990 belum tercapai • AKI Indonesia tertinggi se Asia Tenggara (SDKI 2012-2013)
Penyebab • Direct
• Those resulting from obstetric complications of the pregnant state (pregnancy, labour and the puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above • Indirect • Those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but was aggravated by physiologic effects of pregnancy
Penyebab Kematian Ibu Hemorrhage 24.8%
19,8
7,9 12,9
24,8
12,9 6,9
14,9
Infection 14.9% Eclampsia 12.9% Obstructed Labor 6.9% Unsafe Abortion 12.9% Other Direct Causes 7.9% Indirect Causes 19.8%
Faktor Risiko – 4 Terlalu • Usia Ibu = terlalu TUA, terlalu MUDA • Paritas (terlalu Banyak) • Jarak persalinan (terlalu Sering) “ Unwanted pregnancy “
Causal Pathways in the Reduction of Maternal Mortality • Reduce the likelihood that a woman will become pregnant • Reduce the likelihood that a pregnant woman will experience a serious complication of pregnancy or childbirth • Reduce the likelihood of death among women who experience complications
Program di Indonesia • Cegah/ tunda kehamilan KB • ANC • Pendampingan dan pelatihan dukun bayi • Desa siaga • Peningkatan kualitas Nakes pelatihan nakes, bidan delima • Peningkatan mutu faskes • PONEK, PONED
Safe Motherhood • “ A woman’s ability to have a SAFE and healthy pregnancy and childbirth. ”
Four pillars of safe motherhood
essential obstetric care
clean & safe delivery
antenatal care
family planning
safe motherhood
basic maternity care PRIMARY HEALTH CARE EQUITY FOR WOMEN WHO 1998
FAMILY PLANNING (KB)
Perubahan •Pada kurun waktu 1970-an hingga 1990-an, aspek demografis semata yaitu pengendalian angka kelahiran. •Pasca ditandatanganinya International Conference on Population and Development (ICPD) di Cairo Tahun 1994, telah terjadi pergeseran paradigma yang cukup signifikan dalam pelaksanaan program KB yaitu dari pendekatan demografis menjadi mengedepankan aspek hak-hak asasi manusia.
Undang-Undang Nomor 10 Tahun 1992 tentang Perkembangan Kependudukan dan Pembangunan Keluarga Sejahtera
Undang Nomor 52 Tahun 2009 tentang perkembangan Kependudukan dan Pembangunan Keluarga Keluarga Berencana adalah upaya mengatur kelahiran anak, jarak dan usia ideal melahirkan, mengatur kehamilan melalui promosi, perlindungan dan bantuan sesuai dengan hak reproduksi untuk mewujudkan keluarga berkualitas.
Interventions: Traditional Birth Attendants Advantages • Community-based • Sought out by women • Low tech • Teaches clean delivery
Disadvantages • Technical skills limited • May keep women away from life-saving interventions due to false reassurance
Interventions: Antenatal Care • Antenatal care clinics started in US, Australia, Scotland between 1910–1915 • New concept - screening healthy women for signs of disease • By 1930’s large number (1200) ANC clinics opened in UK • No reduction in maternal mortality • However, widely used as a maternal mortality reduction strategy in 1980’s and early 1990’s Is ANC important? YES!! • Early detection of problems and birth preparation
Maternal Mortality: UK 1840–1960 500 450 400 350 300 250 200 150 100 50 0 18 40 18 50 18 60 18 70 18 80 18 90 19 00 19 10 19 20 19 30 19 40 19 50 19 60
Maternal Deaths
Improvements in nutrition, sanitation Maine 1999.
Antenatal care
Antibiotics, banked blood, surgical improvements
Interventions: Skilled Attendant at Childbirth • 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.
Maternal deaths per 1000000 live births
The higher the proportion of deliveries attended by skilled attendant in a country, the lower the country’s maternal mortality ratio 2000 1800 R2 = 0.74 1600
Y
Log. (Y)
80
90
1400 1200 1000 800 600 400 200 0 0
10
20
30
40
50
60
% skilled attendant at delivery
70
100
Summary Skilled attendant at childbirth is the most effective intervention
WHO 1999.
Program memperbaiki kesehatan anak • Imunisasi • Rehidrasi oral • MTBS • ASI eksklusif
PONEK Ponek adalah pelayanan obstetri neonatal esensial / emergensi komperhensif.
Tujuan utama mampu menyelamatkan ibu dan anak baru lahir melelui program rujukan berencana dalam satu wilayah kabupaten kotamadya atau profinsi. Upaya Pelayanan PONEK : 1. Stabilisasi di UGD dan persiapan untuk pengobatan definitif 2. Penanganan kasus gawat darurat oleh tim PONEK RS di ruang tindakan 3. Penanganan operatif cepat dan tepat meliputi laparotomi, dan SC 4. Perawatan intensif ibu dan bayi. 5. Pelayanan Asuhan Ante Natal Risiko Tinggi
PONED ( Pelayanan Obstetri Neonatus Essensial Dasar ) • PONED merupakan kepanjangan dari Pelayanan Obstetri Neonatus Essensial Dasar. • PONED dilakukan di Puskesmas induk dengan pengawasan dokter. • Petugas kesehatan yang boleh memberikan PONED yaitu dokter, bidan, perawat dan tim PONED Puskesmas beserta penanggung jawab terlatih. • Pelayanan Obstetri Neonatal Esensial Dasar dapat dilayani oleh puskesmas yang mempunyai fasilitas atau kemampuan untuk penangan kegawatdaruratan obstetri dan neonatal dasar. • Puskesmas PONED merupakan puskesmas yang siap 24 jam, sebagai rujukan antara kasus-kasus rujukan dari polindes dan puskesmas. Polindes dan puskesmas non perawatan disipakan untuk mealkukuan pertolongan pertama gawat darurat obstetri dan neonatal (PPGDON) dan tidak disiapkan untuk melakukan PONED.
SDG’s
• Target utama mengentaskan kemiskinan • Indonesia menggunakan 3 indikator 1. Pembangunan manusia (human development) – pendidikan dan kesehatan 2. Lingkungan dalam skala kecil (social economic development) 3. Lingkungan besar (environmental development)– ketersediaan kualitas alam dan SDA yg baik
SDG’s 2016-2030 • Tujuan ketiga (13 target), yakni menjamin kehidupan yang sehat dan mendorong kesejahteraan bagi semua orang di segala usia. TARGETS • 3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births • 3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births • 3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases • 3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being
• 3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol • 3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents • 3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes • 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all • 3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination
• 3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate
• 3.b Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all • 3.c Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States • 3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks
