IssueBriefs

UNICEF INDONESIA

OCTOBER 2012

Maternal and child health Issue Brief: Maternal and child health
Critical issues Critical issues Patterns in child mortality
very three minutes, somewhere in Indonesia, Every three minutes, somewhere in Indonesia, a child under the age of five years dies. a child under the age of five years dies . Moreover, Moreover, every hour, a woman dies from everybirth hour,or a woman dies from giving birth or of causes giving of causes related to pregnancy.
related to pregnancy.

Issue Brief: Maternal and child health

Critical issues Indonesias progress on maternal health, the fifth Indonesias progress on maternal health, the fifth Millennium Development Goal has Every three minutes, somewhere in Indonesia, a Millennium Development Goal(MDG), (MDG), has slowed slowed in in recent recent yearsthe . Its Itsage maternal mortality ratio, estimated child under of five years dies . Moreover, years. maternal mortality ratio, estimated at every hour, a woman dies from giving birth or of causes at around around 228per per 100,000 live births, has remained 228 100,000 live births, has remained related to pregnancy. stubbornly above 200 over over the the past decade, stubbornly above 200 decade, despite despite efforts to improve maternal health services. Poorer efforts to improve maternal health services. Poorer Indonesias progress on maternal health, the fifth countries theregion regionshow show greater greater progress progress in countries inin the in this this Millennium Development Goal (MDG), has slowed in regard (Figure 1). recent years. Its maternal mortality ratio, estimated at regard (Figure 1).
stubbornly above 200 over the past decade, despite Figure 1. Maternal mortality trends, selected ASEAN countries
Source: UN Maternal Mortality Estimation Group: WHO, UNICEF, UNFPA, World Bank

In both rural and urban areas and across all wealth ost of Indonesias child deaths now take quintiles, progress in reducing the neonatal place during the neonatal period, the first mortality rate has stalled in recent years . The 2007 month of life. Theand probabilities of the child2007) Indonesia Demographic Health Survey (IDHS shows that both under-five rate and dying at different ages are 19 mortality per thousand for neonatal the mortality rate have increased in from the highest wealth neonatal period; 15 per thousand 2 to 1 1 months In quintile, both rural and urban areas and across all wealth but the reasons are unclear (Figure 2). As and 10 per thousand from age one to five years. quintiles, progress in reducing the neonatal Although rural households still have an under-five in other developing countries attaining middle income mortality rate has stalled in recent years . The 2007 mortality rate one-third higher than that in urban status, Indonesias child mortality due to infections Indonesia Demographic and Health Survey (IDHS 2007) households, one study shows that rural mortality rates and other childhood illnesses has declined, as mothers shows that both under-five mortality rate andthat neonatal are falling faster than urban rates, and urban
mortality rate have increased in the highest wealth education, household and environmental hygiene, quintile, but the reasons are unclear (Figure 2). income and access to health services have improved. Although rural households still have an under-five Neonatal mortality is higher now the main hurdle mortality rate one-third than that in urbanin reducing further child one deaths. of the causes of neonatal households, studyMost shows that rural mortality rates are falling than urban rates, and that urban deaths are faster preventable.

around 228 per 100,000 live births, has remained

efforts to improve maternal health services. Poorer Maternal deaths countries in the region show greater progress in this 700 per 100,000 live births regard (Figure 1).
600

Figure 1. Maternal mortality trends, selected ASEAN countries 500

Source: UN Maternal Mortality Estimation Group: WHO, UNICEF, UNFPA, World Bank

400

700

Maternal deaths per 100,000 live births

300 600 200 500

400 100 300 0 1990 200 100
Indonesia's MDG target = 102

Philippines

1995

2000

2005
Philippines

2010

Indonesia's MDG target = 102

2015

Indonesia is doing much better reducing infantIndonesia is doing much better in in reducing infant0 1990 1995 2000 the 2005 2010 20151990s and under-five mortality, the fourthMDG. MDG . The The 1990s and under-five mortality, fourth showed a steady progress in reducing the under-five showed a steady progress in reducing the under-five mortality rate, together with its components, infant mortality rate, together with its components, infant Indonesia is doing much better in reducing infantmortality and neonatal mortality rates. In recent years, mortality and neonatal mortality rates. In recent years, and under-five mortality, the fourth MDG . The 1990s however, the reduction of neonatal mortality appears to showed a steady progress in reducing the under-five however, the reduction of neonatal mortality appears have stalled. If this trend continues, Indonesia may not mortality rate,If together with continues, its components, infant may toachieve have stalled. this trend Indonesia the MDG targets for child mortality reduction by mortality and neonatal mortality rates. In recent years, not achieve the MDG targets for mortality 2015, although it appeared to bechild on track in earlier however, the reduction of neonatal mortality appears to years. reduction by 2015, although it appeared to be on not track have stalled. If this trend continues, Indonesia may in earlier years. achieve the MDG targets for child mortality reduction by

mortality has even increased in the neonatal period. These trends appear to be associated with rapid urbanization, leading to overcrowding and poor sanitation conditions amongst the urban poor, exacerbated byincreased changes in the society that period. have led to the In both rural and urban areas and across all wealth mortality has even in neonatal loss of traditional social safety nets. The suboptimal These trends appear to be associated with rapid quintiles, progress in reducing the neonatal mortality urbanization, leading to and poor quality of services inovercrowding poor urban areas could also be a rate has stalled in recent years. The 2007 Indonesia sanitation conditions amongst the urban poor, contributing factor.

Patterns in child mortality years.

2015, although it appeared to be on track in earlier

Demographic and Health Surveythat (IDHS 2007) exacerbated by changes in society have led to shows the that both under-five mortality rate and neonatal loss of traditional social safety nets. The suboptimal Child mortality is associated with poverty. Children quality of poorest services in increased poor urban areas also be a mortality rate have in the could highest wealth in the households generally have under-five contributing factor. quintile, but the reasons are unclear (Figure 2). mortality rates more than twice as high as those in the wealthiest quintile. This isstill because wealthier Although rural households have an under-five Child mortality is associated with poverty. Children households have more access to quality mortality rate one-third higher than that inhealth urbanand in the poorest households generally have under-five social services, better health-seeking practices and households, one study shows that rural mortality rates mortality rates more than twice as high as those in the generally higher levels of education. wealthiest This urban is because wealthier are falling quintile. faster than rates, and that urban
households have more access to quality health and Child mortality rates in poor peri-urban areas are social services, better health-seeking practices and much higher than of the urban average. A study of generally higher levels education.

unite for children

Most of Indonesias child deaths now take place during the neonatal period, the first month of life. Patterns in child mortality The probabilities of the child dying at different ages are Most of Indonesias child deaths now take place 19 per thousand for the neonatal period; 15 per during the neonatal first of life. thousand from 2 to 11period, monthsthe and 10 month per thousand The probabilities of the child dying at different ages from age one to five years. As in other developing are 19 per thousand for the neonatal period; 15 per countries attaining middle income status, Indonesias
thousand from 2 to 11 months and 10 per thousand

Child rates in poor peri-urban areas are andmortality Surabaya in 2000 found child mortality rates up to much higher than the urban average. A study of five times higher in Jabotabeks poor peri-urban 1), Bandung mega-urban Jabotabek subdistrictsJakarta than in(called Jakarta city centre. The higher child and Surabaya 2000 found child mortality rates up to mortality is in attributed to diseases and conditions five times higher in Jabotabeks poor peri-urban associated with crowding, and by poor water quality and subdistricts than in Jakarta city centre. The higher child sanitation. mortality is attributed to diseases and conditions

mega-urban Jakarta (called Jabotabek1), Bandung

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OCTOBER 2012

mortality has even increased in the neonatal period. These trends appear to be associated with rapid urbanization, leading to overcrowding and poor sanitation conditions amongst the urban poor, exacerbated by changes in society that have led to the loss of traditional social safety nets. The suboptimal quality of services in poor urban areas could also be a contributing factor.

Ministry of Health has projected a rise in HIV infection among children.

Disparities in health services

particularly high in West Sulawesi, South Kalimantan, particularly high in West Sulawesi, South Kalimantan, West Nusa Tenggara and exceeding the Child mortality rates inWest poorSumatra, peri-urban areas are West Nusa Tenggara and West Sumatra, exceeding the under-five mortality rates in better-off provinces such as much higher than the in urban average. A study of under-five mortality rates better-off provinces such as Central Kalimantan, Central Java and Yogyakarta. 1 Central Kalimantan, Central Java and Yogyakarta. mega-urban Jakarta (called Jabotabek ), lower, Bandung Whilst the mortality rates in Java are generally Whilst the mortality rates in Javachild are generally lower, and Surabaya in 2000 found mortality this nonetheless translates into large numbers of rates up this translates into large numbers of to nonetheless five women times higher in Jabotabeks poor peri-urban affected and children, an important affected women and children, an important subdistrictsin than in Jakarta city centre. The higher consideration targeting efforts. consideration in targeting efforts.

Child mortality is associated with poverty. Children in the poorest households generally have under-five mortality rates more than twice as high as those in the wealthiest quintile. This is because wealthier households have more access to quality health and social services, better health-seeking practices and generally higher levels of education.

uality maternal and neonatal health services can prevent a large proportion of deaths. In Indonesia, the neonatal mortality rate amongst children whose mothers received antenatal care and delivery assistance by a medical professional was one-fifth of that amongst children whose mothers did not receive these services. Figure 4 provides an overview of the coverage of selected maternal and neonatal health services in Indonesia.

Children of less educated mothers have associated with crowding, and by generally poor water quality Children of less educated mothers generally have higher mortality rates than those born to betterand sanitation. higher mortality rates than those born to bettereducated mothers. In the period 1998-2007, the infant educated mothers. In the period 1998-2007, the infant mortality rate amongst children of mothers with no mortality rate amongst children of mothers with no Geographic disparities are striking: under-five education was 73 per 1,000 live births, whilst that education was 73 per 1,000 live births, whilst thatthree mortality rates of are over 90 per thousand amongst children mothers with secondary orin higher amongst children of mothers with secondary or higher eastern provinces 3).births. Neonatal education was 24 per(Figure 1,000 live The mortality difference is is education was 24 per 1,000 live births. The difference is particularly high health in West Sulawesi, South and Kalimantan, attributed to better seeking behaviour attributed to better health seeking behaviour and knowledge amongst educated women. West Nusa Tenggara and West Sumatra, exceeding knowledge amongst educated women.

child mortality is attributed to diseases and conditions

Quality maternal andIn neonatal health services can educated mothers. the period 1998-2007, the infant Quality maternal and neonatal health services can prevent a large proportion of deaths. In Indonesia, mortality rate amongst children of mothers with prevent a large proportion of deaths. In Indonesia,no the neonatal mortality rate amongst children whose education 73 per 1,000 live births, whilst that the neonatal was mortality rate amongst children whose mothers received antenatal care and delivery mothers received antenatal carewith and delivery amongst children of mothers secondary or higher assistance by a medical professional was one-fifth of assistance by a medical professional was one-fifth of education was 24 per 1,000 live births. The difference that amongst children whose mothers did not receive that amongst children whose mothers did not receive is attributed better seeking behaviour and these services.to Figure 4 health provides an overview of the these services. Figure 4 provides an overview of the knowledge amongst educated women. coverage of selected maternal and neonatal health coverage of selected maternal and neonatal health services in Indonesia. services in Indonesia. The proportion births attended by skilled the HIV/AIDSof epidemic. The proportion ofhealth women The proportion of births attended by skilled health personnel has improved steadily from 41 per in amongst has newimproved HIV cases has grown from 34 cent per cent personnel steadily from 41 per cent in 1992 to 82 per cent in 2010. The indicator includes 1992 to 82to per cent in 2010 . The indicator includes in 2008 44 per cent in 2011. Consequently, the only doctors and midwives or village midwives. Still, in only doctors and midwives or village midwives. Still, in seven eastern provinces, one out of Bekasi; every three births 1 The urban area surrounding Jakarta: and Bogor and seven eastern provinces, one out of every three births took place without assistance from any type of health Depok in West Javaassistance Province; Tangerang and South Tangerang took place without from any type of health staff, attended only by traditional birth attendants or in Banten Province. staff, attended only by traditional birth attendants or family members. family members. 2 The proportion of births delivered in a health facility The proportion of births delivered in a health facility remains low at 55 per cent. Over half the women in 20 remains low at 55 per cent. Over half the women in 20 provinces were unable or unwilling to use any type of provinces were unable or unwilling to use any type of

Children of less educated mothers generally have Disparities in health services Disparities inrates health higher mortality than services those born to better-

Indonesia is seeing an increasing feminization such as Central Kalimantan, Central Java and of Indonesia is seeing an increasing feminization of the HIV/AIDS epidemic. The proportion of in women Yogyakarta. Whilst the mortality rates Java are the HIV/AIDS epidemic. The proportion of women amongst new HIV cases has grown from 34 per cent in amongst new HIV cases has grown from 34 per into cent large in generally lower, this nonetheless translates 2008 to 44 per cent in 2011. Consequently, the Ministry 2008 to 44 per cent in 2011. Consequently, thean Ministry numbers of affected women and children, of Health has projected a rise in HIV infection among ofimportant Health hasconsideration projected a rise HIV infection among in in targeting efforts. children. children.

the under-five mortality rates in better-off provinces

West Sulawesi West Sulawesi Maluku Maluku West Nusa Tenggara West Nusa Tenggara East Nusa Tenggara East Nusa Tenggara South Kalimantan South Kalimantan North Maluku North Maluku Central Sulawesi Central Sulawesi Gorontalo Gorontalo North Sumatra North Sumatra Bengkulu Bengkulu Papua Papua West Sumatra West Sumatra West Papua West Papua Southeast Sulawesi Southeast Sulawesi West Kalimantan West Kalimantan Banten Banten Riau Islands Riau Islands Lampung South Lampung Sulawesi South SouthSulawesi Sumatra South Sumatra West Java West Java Riau Riau Jambi Jambi Bangka Belitung Bangka Belitung East Java East Aceh Java Aceh North Sulawesi North Sulawesi East Kalimantan East Kalimantan Bali Bali DKI Jakarta Jakarta Central DKI Kalimantan Central Kalimantan Central Java Central Java DI Yogyakarta DI Yogyakarta

NMR NMR IMR IMR U5MR U5MR

Figure 3. Under-five, Figure 3. Under-five, infant & neonatal infant & neonatal mortality rates (U5MR, mortality rates (U5MR, IMR, NMR) IMR, in the 10-year NMR) period
in the 10-year period preceding the survey. preceding survey. Source:the IDHS 2007 Source: IDHS 2007

D D

0 0

10 10

20 20

30 30

40 40

50 50

60 60

70 70

80 80

90 100 90 100

Indonesia is seeing an increasing feminization of

ealth cent in des till, in births ealth or

OCTOBER 2012

ISSUE BRIEFS

facility n in 20 e of es. kely to n care e with

women received the complete set of the first five interventions, according to Riskesdas 2010. Even in Yogyakarta, the province with the highest coverage, this proportion was only 58 per cent. Central Sulawesi has the lowest coverage at 7 per cent.

made their ent) in the h. and 8 enatal

Some 38 per cent of reproductive aged women reported having received two or more tetanus toxoid injections (TT2+) during pregnancy. The Ministry of Health recommends that women receive two tetanus toxoid injections during the first pregnancy, with booster injections once during each subsequent pregnancy to maintain full protection. The lowest TT2+ coverage was found in North Sumatra (20 per cent) and the highest in Bali (67 per cent). The quality proportion of births attended by skilled health The of care received during antenatal visits personnel has improved steadily from 41 per cent in is inadequate. Indonesias Ministry of Health 1992 to 82 per cent in 2010. The indicator includes recommends the following components of quality antenatal care: (i) midwives height andor weight measurements, (ii) only doctors and village midwives. Still, in seven eastern provinces, one out of every three births took place without assistance from any type 2 of health staff, attended only by traditional birth attendants or family members. The proportion of births delivered in a health facility remains low at 55 per cent. Over half the women in 20 provinces were unable or unwilling to use any type of health facility, delivering instead in their own homes. Women who deliver in a health facility are more likely to have access to emergency obstetric and newborn care services, although this is not necessarily the case with all health facilities. Some 61 per cent of women age 10-59 years made the required four antenatal care visits during their last pregnancy. Most pregnant women (72 per cent) in Indonesia make the first visit, but drop out before the four visits recommended by the Ministry of Health. Some 16 per cent of women (25 per cent of rural and 8 per cent of urban women) never received any antenatal care during their last pregnancy. The quality of care received during antenatal visits is inadequate. Indonesias Ministry of Health recommends the following components of quality antenatal care: (i) height and weight measurements, (ii) blood pressure measurement, (iii) iron tablets, (iv) tetanus toxoid immunization, (v) abdominal examination, and in addition, (vi) testing of blood and urine samples and (vii) information on the signs of pregnancy complications. Some 86 and 45 per cent of pregnant women respectively had blood samples taken and were informed on the signs of pregnancy complications. However, only 20 per cent of pregnant About 31 per cent of post-partum mothers received timely postnatal care. This means care within 6 to 48 hours after birth, as defined by the Ministry of Health. Good postnatal care is critical, as most maternal and neonatal deaths occur in the first two days and postnatal care is necessary to treat complications following the delivery. Riau Islands, East Nusa Tenggara, Papua are the worst performers in this respect, the coverage of timely postnatal care being only 18 per cent in Riau Islands. Some 26 per cent of all post-partum mothers never received any postnatal care. Amongst maternal health services, facility-based delivery has the greatest disparities (Figures 4 and 5). The proportion of facility-based deliveries in urban areas is 113 per cent higher than that in rural areas. The proportion of women from the highest wealth quintile delivering in health facilities is 111 per cent higher than that from the poorest quintile. With respect to other services, wealth disparities are greater than urban-rural disparities. The urban-rural differential is 9 to 38 per cent for services relating to antenatal care, TT2+, delivery and postnatal care services, but the differentials between wealth quintiles range from 34 to 68 per cent. The relatively low coverage of timely postnatal care services is more likely due to the lack of priority amongst women for these services, than to difficulties in access or availability.

Barriers

he poor quality of antenatal, delivery and postnatal health care services is a major barrier to reducing maternal and child deaths. Across all population groups, the coverage on indicators relating to service quality (e.g., quality antenatal care) is consistently lower than that relating to quantity or access (e.g. four antenatal visits). A 2002 study showed that the
3

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poor quality of care was a contributing factor in 60 per cent of the 130 maternal deaths examined.

OCTOBER 2012
behaviour change amongst mothers and health workers. For example, the IDHS 2007 reports that only 61 per cent of children under age five with diarrhoea were treated with oral rehydration therapy. Mothers are not aware of the importance of breastfeeding. The 2007 IDHS showed that less than one in three infants under the age of six months were breastfed exclusively. The majority of infants in Indonesia are therefore not receiving the benefits of breastmilk in terms of nutrition and protection against disease. Poor sanitation and hygiene practices are widely prevalent. Riskesdas 2010 reports that some 49 per cent of households in Indonesia use unsafe means of excreta disposal, and 23 to 31 per cent of households in the poorest two quintiles still practice open defecation. Such practices are associated with diarrhoeal disease. Riskesdas 2007 reports diarrhoea as the cause of 31 per cent of deaths between the ages of 1 month to a year, and 25 per cent of deaths between the ages of one to four years old. Poor feeding and other care practices contribute to maternal and child malnutrition, an underlying cause of child death. One out of every three children is stunted, and in the poorer quintiles, one out of every four to five children is underweight. Nationally, six per cent of young children are severely wasted, which places them at high risk of death.

The poor quality of public health care shows the need to increase government spending on health. Indonesia has one of the lowest total health expenditures, at 2.6 per cent of its gross domestic product in 2010. Public health expenditures constitute just under half of total health spending. At district level, the health sector receives only 7 per cent of the total sub-national funds, and the Special Allocation Fund (DAK) for health constitutes, on average, less than one per cent of the total budget of the local government. Planning processes for DAK need to become more efficient, effective and transparent. At central level, parliamentary representatives play significant roles in determining funding allocation for their respective districts, and in doing so, slow down the DAK process considerably. Health funding is available at district level only late in the fiscal year. Various barriers prevent poor women from fully realizing the benefits of Jampersal, the Governments health insurance programme for pregnant women. The barriers include insufficient reimbursement levels, especially when the costs of transport and complications are included, and a lack of awareness amongst women of the eligibility for and benefits of Jampersal. On the supply side, there needs to be more health facilities offering Comprehensive Emergency Obstetric and Newborn Care (CEONC) services and more obstetrician-gynaecologists. Indonesias CEONC facility-population ratio (0.84 per 500,000) is still below the ratio of one per 500,000 recommended by UNICEF, WHO and UNFPA (1997). Indonesia has around 2,100 obstetrician-gynaecologists (or one per 31,000 women of reproductive age), but not equitably distributed. More than half the obstetriciansgynaecologists practice in Java. Inappropriate behaviour and the lack of knowledge contribute to child deaths:
Mothers and community health workers lack knowledge on preventing or treating common childhood diseases. In Indonesia, one in three children under the age of five suffers from fever (which could be due to malaria, acute respiratory and other infections), and one in seven suffers from diarrhoea. A large proportion of deaths from these diseases is preventable. However, this requires knowledge, timely recognition, treatment and 4

Opportunities for action

verall, Indonesias health spending needs to increase, including the proportion of DAK going to the health sector. Increasing health spending should go hand-in-hand with tackling the remaining financial and other barriers that prevent poor women from accessing quality health services. A clear delineation is needed between the roles of central and sub-national levels in health care provision. Standards and regulation are part of the central level stewardship function and should not be devolved to sub-national level. Maternal and child health services need a shift in focus to quality, including delivery at facilities equipped with emergency obstetric and neonatal care services. The shift to quality needs action at several levels.
The central level needs to develop and enforce standards and guidelines on the quality of services. Rigorous monitoring is needed to ensure the

OCTOBER 2012
implementation of standards by both public and private health care providers. Private health care needs to be part of government health policies and frameworks. Current efforts to improve health care standards are disproportionately targeting government facilities. Yet three times as many deliveries took place in private facilities than in public facilities in the period 1998-2007. Private health care providers and training facilities are already significant parts of the Indonesian health system and therefore need to be part of government health policies, standards and information systems. Regulation, inspection and certification should ensure the compliance of private providers with government standards and information systems. More facilities providing CEONC services need to be established. At the same time, referral systems should be strengthened to promote appropriate use of these facilities. The move towards quality will require additional resources to develop and motivate health staff. The performance of staff depends on both skills and motivation. Building skills requires not just more training, but rather, facilitative supervision of case management, and for professionals, peer-review assessment, periodical supervision, and critical event or mortality audits. Continuous feedback, monitoring and supervisory sessions play an important role, not only in improving quality but also in motivating teams. Indonesia may wish to consider incentives for health staff. These could be non-financial (enhanced role, ownership, and professional recognition), financial (adding a performance-based component to the salary), or institutional and team-based (measures such as accreditation systems and friendly competitions). A robust information system is one of the components of quality health services. Health information systems across Indonesia are not performing as well as they did before decentralization. Administrative data is poor in many of the districts, making it impossible for the district health team to effectively plan and target interventions. The central level needs robust data for discharging its stewardship function. The situation may require re-centralizing and harmonizing certain functions relating to health information systems, especially with regard to processes, reporting and standards.

ISSUE BRIEFS
be unattainable. The standards should accommodate Indonesias wide disparities and different baselines, for example, by formulating progress in terms of percentage increase rather than a fixed level. This would allow districts to develop more realistic action plans. The setting of certain standards will need to consider geographic realities, population density and the availability of human resources. The Government should support districts or cities that lack the infrastructure to achieve the minimum service standards.

To realize the full benefits of decentralization, district health teams need central and provincial support in evidence-based planning and implementation. Decentralization increases the potential for local governments to plan, budget, and implement programmes tailored to local needs, but this will happen only if the local capacities are adequate. The province level needs resources to help districts plan and implement interventions that improve quality and coverage. Preventive health programmes need to be promoted and accelerated. This will require promoting a continuum of care starting from the adolescent and pre-pregnancy period and continuing throughout pregnancy, delivery and childhood. Interventions should include proven, cost-effective interventions such as community-based case management of common childhood illnesses, breastfeeding promotion and counselling, provision of folic acid supplementation in the preconception stage, maternal anthelmintic therapy, maternal and infant micronutrient supplementation, and maternal and infant use of insecticide-treated bed nets. Elimination of parent to child HIV transmission will require provider-initiated HIV testing and counselling for all pregnant women as part of routine antenatal care, more rigorous follow-up, and better public education.

Resources
Adair, T. (2004). Child Mortality in Indonesias MegaUrban Regions: Measurement, Analysis of Differentials, and Policy Implications. 12th Biennial Conference of the Australian Population Association, 15-17 September 2004, Canberra. BPS-Statistics Indonesia (2011): Susenas 2010: National Socio-Economic Survey. Jakarta: BPS BPS-Statistics Indonesia and Macro International (2008): Indonesia Demographic and Health Survey (IDHS 2007). Calverton, Maryland, USA: Macro International and Jakarta: BPS.

At national level, the existing minimum service standards (SPM) need review and reformulation. Many poor districts consider the current standards to

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Lawn, J.E., Cousens, S., and Zupan, J. (2005): 4 million neonatal deaths: When? Where? Why? Lancet, 365: 891-900 Ministry of Health (2000): Petunjuk pelaksanaan program imunisasi di Indonesia (Guidelines for the implementation of immunization program in Indonesia) Jakarta, Indonesia: Ministry of Health Ministry of Health (2001a): National Strategic Plan for Making Pregnancy Safer (MPS) in Indonesia 2001-2010. Jakarta, Indonesia: Ministry of Health Ministry of Health (2001b): Yang perlu diketahui petugas kesehatan tentang kesehatan reproduksi (What health service providers need to know about reproductive health) Jakarta, Indonesia: Ministry of Health Ministry of Health (2008): Laporan Nasional: Riset Kesehatan Dasar (Riskesdas) 2007, Jakarta: Ministry of Health, National Institute of Health Research and Development. Ministry of Health (2011): Laporan Nasional: Riset Kesehatan Dasar (Riskesdas) 2010, Jakarta: Ministry of Health, National Institute of Health Research and Development.

Nguyen, K.H., Bauze, A.E., Jimenez-Soto, E. and Muhidin, S. (2011). Indonesia: developing an investment case for financing equitable progress towards MDGs 4 and 5 in the Asia-Pacific region: Equity Report. Brisbane, Australia: School of Population Health, the University of Queensland SMERU (2008): The Specific Allocation Fund (DAK): Mechanisms and Uses. Jakarta: SMERU Research Institute Supratikto, G, Wirth, M.E., Achadi, E., Cohen, S. and Ronsmans, C. (2002): A district-based audit of the causes and circumstances of maternal deaths in South Kalimantan, Indonesia. Bulletin of the World Health Organization, 80(3):22834. UNICEF, WHO and UNFPA (1997): Guidelines for Monitoring the Availability and Use of Obstetric Services. New York: UNICEF. World Bank (2010): Indonesia Health Sector Review. Accelerating Improvement in Maternal Health: Why reform is needed. Policy and Discussion Notes, August 2010. Jakarta: World Bank World Bank: World Development Indicators database. Available from: http://data.worldbank.org/data-catalog/ world-development-indicators Accessed 7 August 2012.

This is one of a series of Issue Briefs developed by UNICEF Indonesia. For more information, contact jakarta@unicef.org or go to www.unicef.or.id