Indonesia is a fast-rising economic power that has made significant progress toward key development goals including reducing child mortality. But for reasons outlined in a National Academy of Sciences report by U.S. and Indonesian experts, the nation's estimated rates of maternal and neonatal mortality remain tragically high. The report, highlighted at a joint U.S.-Indonesian public event in Jakarta Jan. 30, makes sweeping recommendations to advance the safety of childbirth in Indonesia.
"Indonesia still has a very significant challenge when it comes to maternal and newborn and child mortality," said NAS report committee co-chair Dr. Eli Y. Adashi, professor of obstetrics and gynecology in the Warren Alpert Medical School of Brown University.
Among the consensus findings of the committee, also led by Mayling Oey-Gardiner, professor of economics at the University of Indonesia, is that the national government's current efforts to address the problem, including producing more than 150,000 midwives in just six years, have fallen short.
Complicated medical problems can arise in any delivery and can require interventions such as cesarean section surgery, Adashi said. Instead of maintaining a health care system in which most women give birth in their home or the home of a midwife, with only a midwife's assistance, Adashi said, the committee recommends that Indonesia build up a tiered infrastructure of certified obstetric health care facilities and provide transportation capabilities, such as medical helicopters, to ensure that women in the archipelago nation can reach those facilities. The nation also must improve the insufficient training of its cadre of midwives, he said, but more importantly increase the supply of obstetric and neonatal nurses and doctors as well.
"We know what works elsewhere in the world, and we know that what's in place is not working," Adashi said. "In a sense we are saying, 'You really have to abandon the current strategy because it's not working and go to what is the working model.'"
Adashi said the committee knows its recommendations are "audacious and ambitious" rather than incremental, but that anything less would likely not help Indonesia reduce a lifetime maternal death risk that for the year 2010 was estimated to be 1 in 210. That risk ranked third highest among the 10 ASEAN member states.
In all, the report features eight recommendations:
Build up a network of basic and more comprehensive obstetric and newborn care facilities that are staffed and equipped to handle deliveries and complicated emergencies 24 hours a day, seven days a week. Formulate strategic plans on five-, 10-, and 20-year time horizons to provide high coverage of quality maternal and neonatal health services across the country.
Centralize the system of obstetric and neonatal care—and the training and licensing of providers—under a central government authority that is represented down to the municipal level around the country.
Revise training for doctors and nurses who specialize in obstetrics, neonatal care, and anesthesia services. Strengthen the training of midwives to recognize emergencies and to create birth plans for delivery at a certified facility.
Develop sufficient and effective financing mechanisms for obstetric and newborn services. Improve data gathering, such as by establishing a registry of maternal and neonatal outcomes including deaths. Current data regarding outcomes are based on household surveys that have sometimes proven to be statistically unreliable.
Integrate Indonesia's strong corps of local community health volunteers into an overall system that promotes health further, by facilitating transportation, birth planning, and postnatal health services.
Expand education for women and girls to empower them with knowledge about childbirth issues. "In Indonesia, more than 60 percent of the women who die in childbirth have not had the benefit of a primary education," the authors wrote in the report.
With investments in better facilities, transportation, and medical training and education in Indonesia, childbirth can become much safer for mothers and babies, Adashi said.