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Obs-Gyn in Indonesia

Andianto Indrawan T
Indonesia (インドネシア)
• Population: estimated around 265.555.7241 as of 22 January 2018 -
4th country with the most population
• Area: 1.910.931 km2 = 5x Japan.
• Archipelago - The largest archipelagic state and island state in the
world by area and population. Ranked 14 in the world2
• Religion: 87.2% Islam, 7% Protestant,
Catholic 2.9%, Hinduism 1.6%, Buddhism 0.72% 11
OBGY specialist in Indonesia (SpOG)
• Total number = 71263 (2017)
• Ratio = about 1/76.000 while ideal ratio 6/100.000 based on
Indonesia Sehat Indicator 2010
• POGI = Indonesian Obstetric and Gynecologist Association
• Available consultants = oncology, fertility, fetomaternal,
urogynecology-reconstruction, social obstetrics.
• More concentrated in big city4 (ex: in Jakarta there are about 740
SpOG 2015)
OBGY education
• About more or less 18 public universities offer the education
• Finish more or less 4.5-6 years ( depends on the university)
• There are selections (written test, interview test, some OSCE) and
requirements ( ex: minimum GPA 2.75, age maximum 35, TOEFL score
>500 etc)5
• We don’t get paid, but pay for our education.
• In the end there is national board test
• After finish education, we must practice in small city/area for 1 year
(compulsory as of 2017)6,7,8
Epidemiology

• Fertility rate = 2.49,10


• Average marriage age = men 25.7, women 22.39
• About 80% of delivery in Indonesia is helped by medical service
provider and in health care facility. ( Indonesia Health Profile 2015)
• About 90% of the pregnant mother in Indonesia have at least 4 times
check up in their pregnancy ( Indonesia Health Profile 2015)
Maternal Mortality Rate • WHY?
• 3 Late
• to make decision
• to reach destination
• for treatment because
of resource
• 4 Too
• Young
• Old
• Many
• Close

Some area have very low number of birth


rate in the health facilities as low as 26%

Indonesia Health Profile 2015


Cause
• Postpartum Hemorrhage
• Hipertensive Disease in
Pregnancy
• Infection
• Long labor
• Abortion
• Emboli?

Indonesia Health Profile 2015


Health Care System
• Health care system in Indonesia is referral system

ObsGyn Subspecialist

ObsGyn Specialist

General Practitioner
(sometimes with maternal Primary Health
USG Training) Care/ Puskesmas
Midwives/Kader /
people from PHC

“Smart People”

Modified from : https://www.slideshare.net/deniiskandar/indonesia-health-delivery-and-financing-sys


Primary Health Care
• Polindes – ANC basic & counseling
• Poli KIA – Mother and child outpatient
• ANC advanced - 10T (height, blood pressure, fundal height, upper arm
circumference, tetanus toxoid status, iron tablets) + dental screening + blood
test (HIV rapid + Hb) – some PHC
• K1 and K4 – 1st visit and total 4 visits minimally (1 x T1, 1 xT2 and 2 xT3)
• Sometimes maternal USG is available in the PHC
• Contraception (Depo Progestin every month, Implant or IUD copper-T)
• Given the PINK book and evaluation of the high-risk pregnancy in first visit

Picture taken from : http://beranisehat.com/archives/puskesmas-fasilitas-kesehatan-yang-masih-banyak-dikeluhkan/


Instruments used to help reduce MMR in
Indonesia
• Mother and Children Book / Pink Book
• Puji Rochjati Score Card
• Sticker delivery planning
• AMP ( Audit maternal – perinatal )
Pink Book
• This book is given to the mother at the
first visit in the primary health care
• This book is integrated with the children
growth chart can be used up to 5 years
• Used for education (pregnancy, labor,
pueperium and contraception) , medical
records
Poedji Rochjati Score Card • Score 4
• Young age <16
• Old age >35
• Pregnant after 4 year married
• Secondary primigravida
• Pregnant again in less than 2 year
• Short stature <145
• Abortion history
• Maternal disease (TB, DM,
cardiac, anemia, malaria, STD)
• Gemelli / twins / more
• Grande multi ( >P3)
• IUFD
• Postdate
• Polyhydramnion
• Previous assisted delivery
• Score 8
• Previous CS
Start with score of 2, if >= 10 = high risk pregnancy  go to • Breech or transverse
hospital for delivery • Bleeding
• Preeclampsia/Seizure

Image taken from : http://khazanahdokter.blogspot.jp/2008/07/kartu-skor-poedji-rochyati.html


• This sticker is the planning during labor including the
dates, location of delivery, transportation, the person
who will donate blood if needed, and is sticked in front
of the house.
Interesting facts about Indonesia
• Marriage in early age = sometimes arranged marriage
• Sometimes people practice taaruf and it occurs not only in rural
areas, but also in cities.
• Some people in Indonesia, especially in the rural areas, sometimes
believe in alternative therapy (herbal/spiritual) first, rather than
medical professional and in the end the come in the late condition.
And they are very disclosed in giving this information.
• Sometimes autonomy is overridden with family decision.
Dukun Beranak / “Smart people”
• Some Indonesian in the rural area still
believe in the “smart people”
• These people have the knowledge from
their predecessor, but didn’t have any
medical education/training.
• They provide delivery service

• In other field we have also “ sangkal


putung” the people who deals with
fracture and sometimes Indonesian
believes these people with herbal
therapy/ alternatives then come up late
in the hospital, already in bad condition.
https://www.motherandbaby.co.id/article/2014/12/6/2929/Indonesia-Masih-Percaya-Dukun-Beranak
Bibliographies
(1) http://www.worldometers.info/world-population/indonesia-population/
(2) https://en.wikipedia.org/wiki/List_of_countries_and_dependencies_by_area
(3) http://depkes.go.id/resources/download/bahan_rakerkesnas_2017/Badan%20PPSDM%20Keseh
atan.pdf
(4) http://pogijaya.or.id/blog/2015/02/surplus-dokter-spog-dki-tertutup-untuk-anggota-pogi/
(5) http://fk.ui.ac.id/wp-content/uploads/2017/05/Brosur-PPDS_4.4.pdf
(6) http://depkes.go.id/resources/download/bahan_rakerkesnas_2017/Badan%20PPSDM%20Keseh
atan.pdf
(7) http://www.mediaindonesia.com/news/read/96105/wkds-pangkas-ketimpangan/2017-03-13
(8) https://www.pressreader.com/indonesia/kompas/20170808/281986082647561
(9) https://en.wikipedia.org/wiki/List_of_countries_by_age_at_first_marriage
(10) https://data.worldbank.org/indicator/SP.DYN.TFRT.IN/
(11) https://en.wikipedia.org/wiki/Indonesia#Religion
END

Images taken from:


https://www.kkh.com.sg/Pages/Home.aspx
https://www.target.com/p/ultrasound-in-gynecology-ultrasound-in-
gynecology-hardcover-mala-sibal/-/A-51719098
https://www.medscape.com/viewarticle/459894