62954 RepRoductive HealtH at a GLance May 2011 indonesia country context indonesia: MdG 5 status Despite infrastructural setbacks resulting from recent natu- MdG 5a indicators ral disasters, Indonesia has continued to make strides in Maternal Mortality Ratio (maternal deaths per 100,000 live 240 education, literacy and health goals. Mortality for men and births) UN estimatea women has decreased and life expectancy has increased. Between 1971 and 2007, the literacy rate increased from 61 Births attended by skilled health personnel (percent) 73.0 percent to 93 percent overall. The government established a MdG 5B indicators policy in 2001 to involve men in the health care of their wives Contraceptive Prevalence Rate (percent) 61.4 and children. Men are expected to be involved in making Adolescent Fertility Rate (births per 1,000 women ages 15–19) 39.2 decisions relating to family planning, antenatal care, prepa- Antenatal care with health personnel (percent) 93.3 ration for delivery, and children’s immunization and nutri- tion.1 Poverty levels remain high, however, as 29 percent of Unmet need for family planning (percent) 9.1 the population subsists on less than US $1.25 per day.2 Source: Table compiled from multiple sources. a The 2007 DHS estimate is 228. Indonesia’s large share of youth population (27 percent of the country population is younger than 15 years old2) provides a window of opportunity for high growth and MdG target 5a: Reduce by three-quarters, between poverty reduction—the demographic dividend. But for this 1990 and 2015, the Maternal Mortality Ratio opportunity to result in accelerated growth, the govern- ment needs to invest in the human capital formation of its Indonesia has been making progress over the past two decades youth. This is especially important in a context of deceler- on maternal health but it is not yet on track to achieve its 2015 ated growth rate arising from the global recession and the targets.5 country’s exposure to high volatility in commodity prices. Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target Gender equality and women’s empowerment are important 700 for improving reproductive health. Higher levels of women’s 620 600 autonomy, education, wages, and labor market participation 500 440 are associated with improved reproductive health outcomes.3 400 350 MDG In Indonesia, the literacy rate among females ages 15 and 300 270 240 Target above is 89 percent. Approximately equal numbers of girls 200 160 are enrolled in secondary schools compared to boys with a 100 ratio of female to male secondary enrollment of 99 percent.2 0 Over half of adult women participate in the labor force2 that 1990 1995 2000 2005 2008 2015 mostly involves work in agriculture. Gender inequalities Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. are reflected in the country’s human development ranking; Indonesia ranks 94 of 157 countries in the Gender-related Development Index.4 World Bank support for Health in indonesia The Bank’s new Country Assistance Strategy Progress Report under Economic progress and greater investment in human preparation (P123200) was approved by the Bank’s executive Board on capital of women will not necessarily translate into bet- February 24, 2011. ter reproductive outcomes if women lack access to repro- current project: ductive health services. It is thus important to ensure that P113341 ID-Health Professional Education Quality ($77.82m) health systems provide a basic package of reproductive health services, including family planning.3 pipeline projects: P124364 ID-Jamkesmas Refinancing Appraisal date 5/11/2011 P122774 ID-Additional Financing for HPEQ Project Appraisal date 5/9/2011 previous Health project: THE WORLD BANK P073772 ID-Health Workforce & Services (PHP 3) n Key challenges jectables are the most commonly used method (32 percent), fol- lowed by the pill (13 percent). Use of long-term methods such as Fertility intrauterine device and implants are negligible. There are socio- Fertility has been declining over time but remains slightly economic differences in the use of modern contraception among higher among the poorest. Total fertility rate (TFR) decreased women: modern contraceptive use is 58 percent among women from 3.0 births per woman in 1991 to 2.6 births per woman in in the wealthiest quintile and 50 percent among those in the 2002-03 but has since stalled with a TFR of 2.6 in 2007.1 Fertility poorest quintile (Figure 4).1 Similarly, just 40 percent of women is 3.0 among the poorest Indonesians and 2.5–2.8 births per with no education use modern contraception as compared to 58 woman among the other wealth quintiles (Figure 2). TFR is percent of women with secondary education or higher. Rural and slightly lower for urban dwellers (2.3) than for rural-dwelling urban dwellers have similar usage of modern contraception, at 57 women (2.8).1 and 58 percent, respectively. Figure 2 n total fertility rate by wealth quintile Figure 4 n use of contraceptives among married women by wealth quintile 3.1 3.0 3.0 80 2.9 2.8 70 2.8 2.6 Overall 61.4 Overall (All methods) 2.7 60 3.0 3.4 4.7 5.6 2.7 2.6 50 3.1 60.3 59.0 59.1 57.9 2.5 2.5 49.9 2.5 40 2.4 30 2.3 20 2.2 10 Poorest Second Middle Fourth Richest 0 Source: DHS Final Report, Indonesia 2007. Poorest Second Middle Fourth Richest Modern Methods Traditional Methods Adolescent fertility adversely affects not only young wom- Source: DHS Final Report, Indonesia 2007. en’s health, education and employment prospects but also that of their children. Births to women aged 15–19 years old have the Unmet need for contraception is moderate at 9.1 percent1 in- highest risk of infant and child mortality as well as a higher risk dicating that women may not be achieving their desired family of morbidity and mortality for the young mother.3, 6 In Indonesia, size.7 adolescent fertility rate is moderate at 39.2 reported births per 1,000 women aged 15–19 years. Approximately 760,000 births (17 percent) are unwanted or mistimed, illustrating an unmet need for contraception. In South- Early childbearing is more prevalent among the poor. While east Asia, it is estimated that there are 130 hospitalizations for ev- 37 percent of the poorest 20–24 years old women have had a child ery 1,000 women having an unsafe abortion.8 before reaching 18, only 14 percent of their richer counterparts did (Figure 3). Fear of side effects or health concerns are the predominant reasons women do not intend to use modern contraceptives Figure 3 n percent women who have had a child before age 18 in future, not including fertility related reasons (such as meno- years by age group and wealth quintile pause and infecundity). Twelve percent not intending to use con- 40% traception cited fear of side effects as the main reason and ten Poorest Poorest 35% Poorest percent cited health concerns. Five percent expressed opposition 30% to use, primarily by their husband/partner or by themselves.1 25% 20% Richest Cost (2.5 percent) and access (0.4 percent) are lesser concerns, 15% Richest indicating further need to strengthen demand for family plan- 10% Richest ning services. 5% 0% 20–24 years 25–34 years >34 years poor pregnancy outcomes Source: DHS Final Report, Indonesia 2007 (author’s calculation). While the majority of pregnant women use antenatal care, Use of modern contraception is increasing.Current use of institutional deliveries are less common. Over nine-tenths of contraception among married women was 61 percent in 2007, pregnant women receive antenatal care from skilled medical an increase from 57 percent in 1997 and 50 percent in 1991.1 personnel (doctor, nurse, or midwife) with 82 percent having More married women use modern contraceptive methods than the recommended four or more antenatal visits.1 A smaller pro- traditional methods (57 percent and 4 percent, respectively). In- portion, 73 percent deliver with the assistance of skilled medical personnel (doctor, nurse midwife, or village midwife). The pro- Hiv prevalence is low in indonesia and knowledge of portion of women who deliver at health facilities is lower at 46 transmission and risk reduction is poor but increasing percent. While 95 percent of women in the wealthiest quintile HIV prevalence is low in Indonesia at 0.2 percent of the popu- delivered with skilled health personnel, only 44 percent of wom- lation ages 15–49 years.2 Of all adults aged 15 years and over en in the poorest quintile obtained such assistance (Figure 5). with HIV, only one fifth are female. Further, 44 percent of all pregnant women are anaemic (defined as haemoglobin < 110g/L) increasing their risk of preterm deliv- Knowledge of HIV prevention methods is increasing slight- ery, low birth weight babies, stillbirth and newborn death.9 ly. 36 percent of Indonesian women and 49 percent of men know that condoms can help reduce risk of transmission. Further, Figure 5 n Birth assisted by skilled health personnel (percentage) knowledge of mother-to-child transmission through breastfeed- by wealth quintile ing has increased from 34 percent of females and 46 percent of 120 males in 2002–03, to 40 percent of females and 48 percent of 100 95.4 males in 2007.1 87.3 78.8 80 73.0% Overall 66.4 60 43.8 40 technical notes 20 Improving Reproductive Health (RH) outcomes, as outlined in the 0 RHAP, includes addressing high fertility, reducing unmet demand for contraception, improving pregnancy outcomes, and reducing STIs. Poorest Second Middle Fourth Richest Source: DHS Final Report, Indonesia 2007. The RHAP has identified 57 focus countries based on poor reproductive health outcomes, high maternal mortality, high fertility Among all women ages 15–49 years who had given birth, 70 and weak health systems. Specifically, the RHAP identifies high priority countries as those where the MMR is higher than 220/100,000 percent received post-natal care from a skilled birth attendant live births and TFR is greater than 3.These countries are also a sub- within two days of delivery, but 17 percent received no postnatal group of the Countdown to 2015 countries. Details of the RHAP are care within 6 weeks of delivery.1 available at www.worldbank.org/population. One quarter of ever-married women report that getting The Gender-related Development Index is a composite index developed money needed for treatment was a big problem in accessing by the UNDP that measures human development in the same dimensions as the HDI while adjusting for gender inequality. Its coverage is limited to health care (Table 1).1 Fifteen percent of women report that 157 countries and areas for which the HDI rank was recalculated distance to the facility was a big problem in accessing health care. Human resources for maternal health are limited with only 0.1 physicians per 1,000 population and 0.82 nurses and mid- national policies and strategies that have influenced wives per 1,000 population.2 Most midwives do not have the req- reproductive health uisite skills for basic emergency obstetric care. Further, there are Indonesia is lagging behind neighboring countries in the relatively few obstetricians and anesthesiologists. implementation of policies that support access to RH. The laws relating to RH, the Population and Family Law (N. 52/2009) and the Health Law (N. 36/2009) stipulate that only married women table 1. n Barriers in accessing health care (women aged 15–49) have access to family planning and contraception; excluding both adolescent and unmarried women from RH services, places them Reason % at greater risk of unwanted pregnancies and sexually transmitted At least one problem accessing health care 40.9 infections. Getting money needed for treatment 25.1 The health Law 36/2009 prohibits abortion and considers induced Distance to health facility 15.3 abortion a crime, except to protect the life of the mother and the Having to take transport 13.3 infant, and in the event of rape. Not wanting to go alone 12.1 The Indonesian Health Insurance Program for the Poor and near- Concern no female provider available 10.6 poor, Jamkesmas, has been providing financial coverage for a number of RH services– for family planning, antenatal care, skilled- Knowing where to go for treatment 5.4 birth attendance, care for normal and complicated deliveries, and Getting permission to go for treatment 4.2 postnatal care—since 2008. Source: DHS final report, Indonesia 2007. n Key actions to improve RH outcomes strengthen gender equality enhance the benefit package to promote utilization of facility • Support women and girls’ economic and social empowerment. based delivery; Increase school enrollment of girls. Strengthen employment • Improve the quality of referral system of obstetric and neo- prospects for girls and women. Educate and raise awareness on natal complications by (i) improving the quality of birth de- the impact of early marriage and child-bearing. livery and management of emergency cases by the midwives, • Educate and empower women and girls to make reproductive (ii) establishing locally appropriate provider referral networks health choices. Build on advocacy and community participation, and (iii) improving quality of care at referral hospitals includ- and involve men in supporting women’s health and wellbeing. ing by increasing the supply of obstetricians and anesthesiolo- gists in underserved areas; Reducing maternal mortality • Revitalize family planning and address unmet needs including • To reduce maternal mortality there are two key focus area on those of unmarried single women; which it is critical to act: improving access to maternal health • Improve maternal and neonatal death surveillance system and services, both physical and financial, and improving demand its use for policy development and decision making at all ad- for quality maternal care. ministrative levels; • Increase overall funding for maternal health and ensure timely and sufficient availability of resources at the local government Reducing stis/Hiv/aids level for locally specific maternal health interventions; • Integrate HIV/AIDS/STIs and family planning services in rou- • Increase the geographic coverage and community understand- tine antenatal and postnatal care. ing of health insurance including the eligibility criteria, and References: 1. Statistics Indonesia (Badan Pusat Statistik-BPS) and Macro 8. Guttmacher Institute. Abortion in Indonesia. 2008. http://www. International. 2008. Indonesia Demographic and Health Survey guttmacher.org/pubs/2008/10/15/IB_Abortion_Indonesia.pdf. 2007. Calverton, Maryland, USA: BPS and Macro International. 9. Worldwide prevalence of anaemia 1993–2005: WHO global da- 2. World Bank. 2010. World Development Indicators. Washington DC. tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, 3. World Bank, Engendering Development: Through Gender Equality Ines Egli and Mary Cogswell. http://whqlibdoc.who.int/publica- in Rights, Resources, and Voice. 2001. tions/2008/9789241596657_eng.pdf. 4. Gender-related development index. http://hdr.undp.org/en/media/ HDR_20072008_GDI.pdf. 5. Trends in Maternal Mortality: 1990–2008: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. correspondence details 6. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. This profile was prepared by the World Bank (HDNHE, PRMGE, and Geneva: WHO. http://www.who.int/making_pregnancy_safer/top- EASHH). For more information contact, Samuel Mills, Tel: 202 473 ics/adolescent_pregnancy/en/index.html. 9100, email: smills@worldbank.org. This report is available on the 7. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra- ception. Human Development Network, World Bank. http://www. following website: www.worldbank.org/population. worldbank.org/hnppublications. indonesia RepRoductive HeaLtH action pLan indicatoRs indicator Year Level indicator Year Level Total fertility rate (births/woman ages 15–49) 2007 2.6 Population, total (million) 2008 227.3 Adolescent fertility rate (births/1,000 women ages 15–19) 2008 39.2 Population growth (annual %) 2008 1.2 Contraceptive prevalence (% of married women ages 15–49) 2007 61.4 Population ages 0–14 (% of total) 2008 27.4 Unmet need for contraceptives (%) 2007 9.1 Population ages 15–64 (% of total) 2008 66.8 Median age at first birth (years) from DHS — Population ages 65 and above (% of total) 2008 5.9 Median age at marriage (years) 2007 19.8 Age dependency ratio (% of working-age population) 2008 49.8 Mean ideal number of children for all women — Urban population (% of total) 2008 51.5 Antenatal care with health /sonnel (%) 2007 93.3 Mean size of households 2007 4 Births attended by skilled health /sonnel (%) 2007 73.0 GNI/capita, Atlas method (current US$) 2008 1880 Proportion of pregnant women with hemoglobin <110 g/L) 2008 44.3 GDP/capita (current US$) 2008 2246 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 620 GDP growth (annual %) 2008 6.1 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 440 Population living below US$1.25/day 2007 29.4 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 350 Labor force participation rate, female (% of female population ages 15–64) 2008 53.3 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 270 Literacy rate, adult female (% of females ages 15 and above) 2006 88.8 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 240 Total enrollment, primary (% net) 2008 98.7 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 160 Ratio of female to male primary enrollment (%) 2008 97.3 Infant mortality rate (per 1,000 live births) 2008 30.7 Ratio of female to male secondary enrollment (%) 2008 99.2 Newborns protected against tetanus (%) 2008 79 Gender Development Index (GDI) 2008 94 DPT3 immunization coverage (% by age 1) 2008 77 Health expenditure, total (% of GDP) 2007 2.2 Pregnant women living with HIV who received antiretroviral drugs (%) 2005 <1 Health expenditure, public (% of GDP) 2007 54.5 Prevalence of HIV (% of population ages 15–49) 2007 0.2 Health expenditure/capita (current US$) 2007 41.8 Female adults with HIV ( % of population ages 15+ with HIV) 2007 20 Physicians (per 1,000 population) 2003 0.1 Prevalence of HIV, female (% ages 15–24) 2007 0.1 Nurses and midwives (per 1,000 population) 2003 0.82 poorest-Richest poorest/Richest indicator survey Year poorest second Middle Fourth Richest total difference Ratio Total fertility rate DHS 2007 3.0 2.5 2.8 2.5 2.7 2.6 0.3 1.1 Current use of contraception (Modern method) DHS 2007 49.9 60.3 59.0 59.1 57.9 57.4 –8.0 0.9 Current use of contraception (Any method) DHS 2007 53.0 63.3 62.4 63.8 63.5 61.4 –10.5 0.8 Unmet need for family planning (Total) DHS 2007 12.8 8.6 8.9 7.3 8.2 9.1 4.6 1.6 Births attended by skilled health personnel DHS 2007 43.8 66.4 78.8 87.3 95.4 73.0 –51.6 0.5 (percent) development partners support for reproductive health in indonesia unFpa: Reproductive health and rights, family planning and gender. usaid: Maternal and neonatal care; promotion of facility based delivery, strengthening response to complications. uniceF: Child protection; under-5 mortality ausaid: Health systems strengthening; qualities of care, emergency obstetric care.