Maternal and Newborn Health Country Profiles

Indonesia
Indonesia is on track to achieve MDG 4, however disparities between rural and urban areas, and within
provinces need attention to ensure equitable child health services. The annual rate of reduction in the
under-5 mortality rate was 4.5 between 1990 and 2011. A focus on neonatal mortality reduction would
accelerate the progress further, as this constitutes almost half of all under-5 mortality. The country has
made considerable strides to improve maternal survival. Refining the quality of antenatal care, turning
attention to the high prevalence of preterm births and increasing coverage of postnatal care would
further reduce preventable maternal and newborn mortality.

TRENDS AND POLICIES

Trends in child mortality

1990

2010

MDG target 2015

Deaths per 1,000 live births

85
56
35

28

31

27
17

Under-5
mortality rate

17

Infant
mortality rate

Neonatal
mortality rate

Trends in maternal mortality

Deaths per 100,000 live births

1990

2010

MDG target 2015

600

220

150

Trends in maternal indicators

Per cent (%)

60

51
24.2
9

Per capita total expenditure on

health (US$), 200720111

77

Out-of-pocket expenditure
(% of private expenditure on health),
200720111

75.1

Specific notification of maternal deaths

Yes

Midwife personnel authorized to

administer core set of lifesaving
interventions

Partial

Costed national implementing plans

for maternal, newborn and child health
available

No

Number of basic emergency obstetric

and newborn care facilities2

1,667

Facilities per 1,000 births3

Community treatment of pneumonia

with antibiotics

No

Oral rehydration solution and zinc for

management of diarrhoea

Yes

DHS 2007

61

Availability

Sources: Confirmed with UNICEF Indonesia Country Office, unless specified; 1World Health
Organization National Health Account database 2012 (retrieved from www.data.worldbank.
org); 2There are 1,667 facilities based on the Indonesian Ministry of Health Facility Survey
2011; 3United Nations Population Fund, The State of the Worlds Midwifery 2012.

Maternal mortality ratio

DHS 2003

National health policies and services

51

22

Contraceptive Unmet family Women 20-24

prevalence rate planning need married before
(met need)
age 18

Adolescent
birth rate

Sources for figures: Trends in child mortality: 1990 and 2010 child data from UN
Inter-agency Group for Child Mortality Estimation, Levels & Trends in Child Mortality, 2011;
Report on Achievement of the Millennium Development Goals Indonesia 2010 (IMR);
Indonesia Demographic and Health Survey (DHS) 2007. Trends in maternal mortality:
2015 targets from Countdown to 2015 Indonesia Country Profile (retrieved from www.
countdown2015mnch.org/country-profiles) and Report on Achievement of the Millennium
Development Goals Indonesia 2010; Indonesia 2007 DHS; Indonesia Ministry of Health,
Ind Riset Kesehatan Dasar/Basic Health Research, 2007. Trends in maternal indicators:
Indonesia Demographic Health Survey (DHS) 2003 and 2007. Notes: Contraceptive prevalence
rate proportion of currently married women aged 1549 who were using some method of
family planning at the time of the survey; unmet family planning need: % of women with an
unmet need for family planning (spacing or limiting); adolescent birth rate: annual number of
births among women aged 1519 per 1,000 women in the age group.

Maternal and Newborn Health Country Profiles: Indonesia

Indicators of quality of care

Antenatal care

95.2

100

Intrapartum/delivery

91
81.5

80

Postnatal care

79

Per cent (%)

70
60

53

46
40

40

32

29

20

6.8
0
ANC1+

ANC4+

BP
Blood
measured* sample*

Urine
sample*

SBA

Inst.
delivery

C-section BF (excl.) PNC within Birth reg.

2 days

Source: Indonesia DHS 2007.

Notes: ANC1+: % of women who received 1 ANC visit; ANC4+: at 4 ANC visits; *% of ANC visit that included measuring blood pressure (BP) and collecting blood and urine samples; SBA: %
of births delivered by a skilled birth attendant (doctor, nurse, midwife); inst. delivery: % of births delivered at a health facility; C-section: % of births delivered by caesarean section; BF (excl.): %
of children younger than 6 months who were exclusively breastfed; PNC within 2 days: % of women who received a postnatal check-up within 2 days of delivery (calculated by adding the sum
of the % of women who received PNC within less than 4 hours, 423 hours and within 2 days of delivery and mentioned in the DHS); birth reg.: % of children younger than 5 years whose birth
was registered with the State.

AVAILABILITY OF NATIONAL POLICIES1 FOR HIGH-IMPACT INTERVENTIONS SHOWN TO

IMPROVE NEONATAL SURVIVAL THROUGHOUT THE CONTINUUM OF CARE2

Preconception

Antenatal4

Intrapartum

Postnatal

- Folic acid
supplementation3

- Tetanus toxoid immunization

- Syphilis screening
- Pre-eclampsia and eclampsia
prevention
- Presumptive malaria treatment
- Detection and treatment of
asymptomatic bacteriuria

- Skilled maternal and

neonatal care
- Emergency obstetric care
- Antibiotics for PROM
- Steroids for pre-term labour
- C-section
- PMTCT
- Labour surveillance
- Clean delivery practices

- Resuscitation of newborn
baby
- Breastfeeding
- Prevention and management
of hypothermia5
- Kangaroo mother care5
- Community-based
pneumonia management
- Emergency neonatal care

Legend: green: policy in place; red: no policy or clear guideline in place.

Sources: 1Polices are addressed/mentioned in the National Strategic Plan of Making Pregnancy Safer Indonesia 20012010, except as indicated; 2Darmstadt et al., 2005; 3Mentioned but no
guidelines indicated in the Ministry of Health Republic of Indonesia and World Health Organization, The National Nutrition Strategy for Children 018 Years, 2005; 4Indonesia Ministry of Health,
Integrated Antenatal Care Guideline (Pedoman Pelayanan Antenatal Terpadu; Edisi kedua, Dirjen Bina Gizi and KIA. Jakarta, 2012; 5Indonesia Ministry of Health, Pocketbook for Essential Newborn
Health Care for Primary Health Services (Buku Saku Pelayanan Kesehatan Neonatal Esensial: Pedoman Tehnis Pelayanan Kesehatan Dasar. Dirjen Bina Kesehatan Masyarakat), Jakarta, 2010.
Notes: PROM: Premature rupture of membranes; emergency obstetric care: management of complications-obstructed labour, haemorrhage, hypertension, infection; C-section: caesarean section
(detection and management of breech); PMTCT: prevention of mother-to-child transmission of human immunodeficiency virus (HIV); labour surveillance (including partograph) for early diagnosis
of complications); kangaroo mother care (care for low birth weight infants in health facilities); emergency neonatal care: management of serious illness (infections, asphyxia, prematurity, jaundice).
Reference: Darmstadt, G.L., Bhutta, Z.A., Cousens, S., Adam, T., Walker, N., De Bernis, L. Evidence-Based, Cost-Effective Interventions: How many newborn babies can we save? in The
Lancet, 2005; 365 (9463).

Maternal and Newborn Health Country Profiles: Indonesia

READINESS FOR NATIONAL SCALING UP OF NEWBORN CARE

Agenda setting

Policy formulation

Policy implementation

- National needs assessment for

newborn care conducted
- Local evidence generated for
newborn survival
- Existence of a convening mechanism
for newborn health issues
- Focal person for newborn health in
Ministry of Health
- Key maternal and newborn indicators
included in national surveys
(e.g. neonatal mortality rate)

- National newborn policy endorsed

- Newborn policy integrated into other
health policies or strategies
- Essential drug list includes injectable
antibiotics for primary level care
- Midwives authorized to perform
neonatal resuscitation
- National targets to track newborn
health established
- Key maternal and newborn indicators
included in national health information
systems
- Community-based cadres authorized
to perform neonatal resuscitation
(midwives)
- Primary-level cadres authorized to
administer injectable antibiotics for
newborn infections (midwives)
- Community-based cadres authorized
to administer injectable antibiotics for
newborn infections (midwives)

- Supervision system for maternal,

newborn and child health established
at primary health centre level
- Protocol or standard for district
hospital care of sick newborns in place
- Integrated management of childhood
illness algorithm adapted to include the
first week of life
- Resource requirement for primary
health care available for newborns
- Resource requirement for secondary-
level health care available for newborns
(not all)
- System for neonatal death audits exists
- System for perinatal death audits exists
- Cadre identified for home-based
newborn care
- In-service newborn care training
materials for community-based cadres
(village midwife)
- In-service newborn care training
materials for facility-based cadres
(village midwife)
- Pre-service newborn care education
for community-based cadres
(village midwife)
- Pre-service newborn care education for
facility-based cadres (village midwife)

Agenda setting

Policy formulation

Policy implementation

- Local evidence disseminated

for newborn survival

- National behaviour change

communication strategy
- Community-based cadres authorized
to administer injectable antibiotics for
newborn infections
- Primary-level cadres authorized to
administer injectable antibiotics for
newborn infections
- Community-based cadres authorized
to perform neonatal resuscitation
(not for voluntary cadres)
- Costed implementation plan for
maternal, newborn and child health
- Reproductive, maternal, newborn and
child expenditure per child younger
than 5 and per woman aged 19-49
- Community-based cadres authorized
to perform neonatal resuscitation
(not for voluntary cadres)
- Primary-level cadres authorized to
administer injectable antibiotics for
newborn infections (not for
voluntary cadres)
- Community-based cadres authorized
to administer injectable antibiotic
for newborn infections (not for
voluntary cadres)

- In-service newborn care training

materials for community-based cadres
(not for voluntary health cadres)
- In-service newborn care training
materials for facility-based cadres
(not for voluntary health cadres)
- Pre-service newborn care education
for community-based cadres
(not for voluntary health cadres)
- Pre-service newborn care education for
facility-based cadres (not for voluntary
health cadres)

Legend: green: benchmark met; red: benchmark not met.

Sources: Moran, A.C. et al., 2012. Availability of benchmarks as per UNICEF Indonesia Country Office.
Reference: Moran, A.C., Kerber, K., Pfitzer, A., Morrissey, C.S., Marsh, D.R., Oot, D.A., Sitrin, D., Guenther, T., Gamache, N., Lawn, J.E., Shiffman, J. Benchmarks to Measure Readiness to
Integrate and Scale Up Newborn Survival Interventions, in Health Policy Planning 2012: 27(iii29-iii39).
Maternal and Newborn Health Country Profiles: Indonesia

CONTINUING INEQUITIES: Indicators by residence, wealth quintiles and provinces

Disparities
Disparitiesby
byresidence
residence

Deaths per 1,000 live births

Deaths per 1,000 live births

U5MR
U5MR

IMR
IMR

Disparities
Disparitiesby
byresidence
residence
Urine
Urine
sample
sample

NMR
NMR

1818

1717

3131
6060

Per cent (%)

Per cent (%)

4545

2727

Deaths per 1,000 live births

Deaths per 1,000 live births

U5MR
U5MR

53.4
53.4

41.4
41.4
87.6
87.6

7373

62.7
62.7

3838

3535

33.2
33.2

49.2
49.2

40.1
40.1

Urban
Urban

Country
Country
total
total

Rural
Rural

Urban
Urban

Country
Country
total
total

Disparities
Disparitiesby
bywealth
wealthquintiles
quintiles
IMR
IMR

Disparities
Disparitiesby
bywealth
wealthquintiles
quintiles
Urine
Urine
sample
sample

NMR
NMR
total
total

SBA
SBA

Birth
Birth
reg.
reg.

83.8
83.8
Per cent (%)
Per cent (%)

2727
5656

2626

1717
2727

3232

3535

Wealthiest
Wealthiest

Country
Country
total
total

1717
7777

Poorest
Poorest

U5MR
U5MR

IMR
IMR

53.4
53.4
95.4
95.4
22.9
22.9

7373

43.8
43.8

56.6
56.6

22.6
22.6
Poorest
Poorest

Most
Mostand
andleast
leastaffected
affectedprovinces
provinces

40.1
40.1

Wealthiest
Wealthiest

Country
Country
total
total

Most
Mostand
andleast
leastaffected
affectedprovinces
provinces
Urine
Urine
sample
sample

NMR
NMR

SBA
SBA

Birth
Birth
reg.
reg.

97.3
97.3

9696

4646
2222

DIY
DIY

1919
WS
WS

DIY
DIY

1313
WS
WS

CKCK

93.8
93.8

69.6
69.6

Per cent (%)

Per cent (%)

7474

WS
WS

Birth
Birth
reg.
reg.

70.5
70.5

2424

Rural
Rural

Deaths per 1,000 live births

Deaths per 1,000 live births

SBA
SBA

32.8
32.8
18.7
18.7

12.8
12.8
Maluku
Maluku

DKIJ
DKIJ

Maluku
Maluku

DKIJ
DKIJ

Maluku
Maluku

DIY
DIY

Sources: Indonesia DHS 2007.

Notes: Comparison of data is by residence (rural versus urban versus country total), wealth quintiles (poorest versus richest versus country total) and by provinces (most affected versus least
affected); urine sample (obtained during ANC visit); SBA: % of pregnancies delivered by skilled birth attendant; birth reg.: % of children younger than 5 years whose birth was registered with the
State. Provinces: WS: West Sulawesi, DIY: DI Yogyakarta, CK: Central Kalimantan, DKIJ: DKI Jakarta.

Maternal and Newborn Health Country Profiles: Indonesia

EQUITY FOCUS: Indicators by residence, wealth quintiles and provinces

Residence
Indicator

Quintiles

Rural

Urban

Poorest Wealthiest

Most and least affected provinces

U5MR (country avg: 35%)

60

38

77

32

M: West Sulawesi (96);

L: DI Yogyakarta (Java; 22)

NMR (country avg: 17%)

24

18

27

17

M: West Sulawesi (46);

L: Central Kalimantan (13)

IMR (country avg: 27%)

45

31

56

26

M: West Sulawesi (74);

L: DI Yogyakarta (Java; 19)

Informed pregnancy complications at ANC,

% (country level: 38.8%)

35.4

43.3

25.7

50.5

M: Maluku (16.1); L: West Java (50.8)

Blood pressure taken (country avg: 90.7%)

88.5

96.4

81.5

98.0

M: Maluku (69.1); L: DKI Jakarta (98.9)

Blood sample taken (country avg: 29.2%)

25.7

33.9

22.6

37.2

M: Maluku (17.6); L: DKI Jakarta (58)

Urine sample taken at ANC, %

(country level: 40.1%)

33.2

49.2

22.6

56.6

M: Maluku (12.8); L: DKI Jakarta (69.6)

Skilled birth attendant at delivery

(country level: 73%)

62.7

87.6

43.8

95.4

M: Maluku (32.8); L: DKI Jakarta (97.3)

Percentage delivered by C-section

(country level 6.8%)

3.9

11

1.8

16.8

M: Central Kalimantan (1.4); L: DKI

Jakarta (13.8)

17

14.5

22.7

10.7

M: Papua (66);
L: DI Yogyakarta (Java; 2.0)

PNC within 2 days (country avg:

70.3%)

70.6

69.1

66.6

67.8

M: Papua 26.9;
L: DI Yogyakarta (Java; 93.5)

Birth registration (country avg: 53.4%)

41.4

70.5

22.9

83.8

M: Maluku 18.7;
L: DI Yogyakarta (Java; 93.8)

Exclusive breastfeeding (country %: 32)

% who received ORS or RHF

(country level %: 46.1)

47.4

43.9

47

38.7

M: North Sumatra (31.8);

L: DI Yogyakarta (Java; 78.9)

% continued feeding and given ORT and/or

increased fluids (country avg: 54.3%)

55.8

51.7

54.5

48.4

M: Banten (33);
L: DI Yogyakarta (Java; 89.7)

% of under-5 children with symptoms of

ARI and/or fever whom advice or treatment
was sought from a health facility or
provider (country avg: 65.9%)

63

70.5

50.6

73.6

M: Maluku 42.6; L: Bali (83.2)

82.8

87.4

71.9

89.2

Antenatal

Intrapartum

Postpartum
No postnatal check-up
(country total: 16.4)

Children younger than 5 years

DPT3 (country avg: 84.8%)

M: West Papua (56.9);

L: Central Java (100)

Sources: All data from DHS 2007 except for U5MR, IMR and NMR totals, which are from UN Inter-agency Group for Child Mortality Estimation, Levels & Trends in Child Mortality, 2011.

Maternal and Newborn Health Country Profiles: Indonesia

Backstopping midwives with life-saving technology

In an innovative arrangement to help midwives improve
their service to women and children at the village level,
Nokia, PT XL Axiata (telecommunications service) and
UNICEF teamed up in 2012 to provide 200 midwives
in West Lombok with a phone and application service
called Nokia Life Info Bidan, which sends useful SMS
information on maternal and child health. West Lombok
is located in West Nusa Tenggara, a province with one of
the highest maternal and child health death rates in the
country. UNICEF and Nokia provide the cellular phones
while PT XL Axiata provides 25,000 rupiah worth of airtime
every month.

Spotlight on UNICEF work

Nokia Life Info Bidan, which sends useful SMS information

on maternal and child health, highlights healthy
practices in pregnancy, safe motherhood, nutrition and
immunization to early child development and learning;
the midwives discuss the messages in mothers classes,
during appointments in the posyandu (health clinics) or
wherever they meet with the community.
I will note the messages down and put them in a book
so that I can discuss them with cadres and community
members although I can only get a cellular signal from
one room in my house, explained Luluk, who lives in
Mareje Timur, a village in the hills some two hours from
the district capital.
The projects baseline survey revealed that all midwives
used a mobile phone and most (85 per cent) were
interested in SMS health information, as were 53 per cent
of their patients. An assessment of midwives knowledge
suggested the SMS messages should focus on areas of
lowest scores postpartum care, pneumonia and malaria.
The initial monitoring reports confirmed a high use rate
(97 per cent) of messages that reached patients through
the midwives.

Maternal and Newborn Health Country Profiles: Indonesia

Employing village midwives in Indonesia has been

a successful strategy to reduce the urbanrural gap
in skilled attendance at delivery. The Governments
village midwife programme (bidan di desa
programme) provided one-year midwifery training
between 1989 and 1996. When a critical mass of
midwives was reached in 1996, the training was
replaced with a three-year diploma course for high
school graduates, which remains in place. Once
trained, the midwives are assigned to a village
or community. This approach has had a positive
impact on linking communities with the formal
health sector and on increasing the coverage of
care for mothers and newborns. Additionally, the
partnership programme in which village midwives
work with traditional birth attendants has had a
positive impact on coverage of care.
Village midwives in Indonesia provide the whole
spectrum of maternal and newborn care, from
promotional to preventive, to curative care. They
conduct deliveries and provide essential pregnancy
and newborn care, including management and
referral for complications. Midwife-assisted
deliveries take place at the patients home or the
village midwifes home. Keeping their professional
knowledge up to date is necessary to provide
quality advice and counselling to clients and it is
important for job satisfaction. Although formal
training opportunities (workshops, seminars, and
meetings) exist, the frequency and coverage are
not optimal.

UNICEF/2012/Hasan

I will note the messages

down and put them in a book
so that I can discuss them
with cadres and community
members although I can only
get a cellular signal from one
room in my house

Background