MCH dan FP (Maternal Child Health & Family Planning) Titik Kuntari Departemen Ilmu Kesehatan Masyarakat FK UII
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.
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)
Maternal Mortality Ratio • Jumlah kematian ibu per 100.000 kelahiran hidup • Indonesia tertinggi se Asteng • Saat ini angka Kematian Ibu di Indonesia masih tinggi yaitu sebesar 228 per 100.000 kelahiran hidup (SDKI 2007), sedangkan target MDGs 2015, angka kematian ibu saat melahirkan harus diturunkan menjadi 102 per 100.000 kelahiran hidup.
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
14,9
Infection 14.9% Eclampsia 12.9%
6,9
Obstructed Labor 6.9% Unsafe Abortion 12.9% Other Direct Causes 7.9% Indirect Causes 19.8%
Faktor Risiko • • • •
Usia Ibu = terlalu TUA, terlalu MUDA Paritas (terlalu Banyak) Jarak persalinan (terlalu Sering) Unwanted pregnancy
Distant Determinants
Intermediate Determinants
Health status
Outcomes
Pregnancy
Reproductive status Socioeconomic and cultural factors
Complication
Access to health services
Death/disability Health care behavior/use of health services
Unknown or unpredicted factors
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
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
UPAYA MENURUNKAN AKI 1. KB 2. ANC 3. Pelatihan dukun tradisional 4. Distribusi tenaga kesehatan terlatih
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.
ISU penting 1. Jumlah penduduk di atas proyeksi 2. Disparitas TFR masih tinggi dan meningkat pada status sosial ekonomi 3. menengah ketas. 4. Kenaikan CPR 1,1 persen dalam 5 tahun 5. Unmet need tinggi 6. Kesertaan MKJP rendah (Metode Kontrasepsi Jangka Panjang) 7. Tingkat Ketidaklangsungan Pemakaian (drop out) Kontrasepsi Meningkat 8. Pelayanan KB di fasilitas pelayanan kesehatan menurun 9. Angka Kematian Ibu tinggi
Historical Review of Interventions
The flawed assumption:
Most life-threatening obstetric complications can be predicted or prevented
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: Traditional Birth Attendants
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
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: Risk Screening 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
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.
