Child survival rates Children’s health and nutrition out comes

99 Box฀3.1:฀Factors฀inluencing฀ immunization฀coverage฀among฀ poor children in urban and rural areas In฀North฀Jakarta,฀immunization฀facilities฀are฀ available฀in฀each฀posyandu integrated health post. Posyandu ฀personnel฀are฀also฀active฀in฀ providing฀information฀about฀about฀child฀health,฀ including฀about฀immunization.฀However,฀the฀ awareness of some poor households is still lacking.฀Ibu฀Asih฀not฀her฀real฀name;฀34฀years฀ old works shucking oysters and has four children;฀three฀of฀them฀are฀already฀in฀primary฀ and฀secondary฀school,฀but฀the฀youngest฀one฀ Widi is still four years old and not yet attending school.฀Widi฀was฀never฀immunized฀at฀the฀ posyandu ฀although฀this฀service฀is฀provided฀for฀ free. Ibu Asih cannot take Widi to the posyandu because the posyandu opens at the same time that฀the฀supply฀of฀oysters฀arrives฀to฀be฀shucked,฀ and nobody else can take Widi to the posyandu. Similarly,฀Ibu฀Inah฀46฀years฀old,฀who฀never฀ finished her primary school education and is now working฀collecting฀unused฀medicines,฀also฀never฀ took฀her฀ten฀children฀to฀be฀immunized฀because฀ she was afraid that her children would become feverish฀after฀being฀immunized.฀She฀did฀not฀ believe฀that฀her฀children฀would฀be฀healthier฀after฀ being฀immunized;฀on฀the฀contrary฀she฀believed฀ it฀would฀make฀them฀ill,฀due฀to฀the฀high฀fever.฀Ibu฀ Yati฀54฀years฀old,฀a฀single฀mother฀who฀now฀has฀ ive฀grandchildren,฀shared฀the฀same฀opinion.฀ She฀never฀allowed฀her฀four฀children฀and฀ive฀ grandchildren฀to฀be฀immunized.฀She฀is฀afraid฀of฀ needles and does not want her grandchildren to be injected with syringes. On฀the฀contrary,฀in฀many฀remote฀villages฀in฀ East฀Sumba,฀a฀lack฀of฀access฀and฀limited฀health฀ facilities are the main hindrance to the expansion of฀immunization฀coverage.฀To฀overcome฀this฀ problem,฀the฀local฀government฀is฀conducting฀a฀ mass฀immunization฀programme฀of฀all฀children฀ under฀ive฀years฀old฀at฀the฀posyandu and using฀the฀PNMP฀GSC฀National฀Programme฀for฀ Community฀฀Empowerment฀–฀Healthy฀and฀Smart฀ Generation฀to฀intensify฀immunization฀activities฀ at the posyandu .฀Parents฀are฀encouraged฀to฀take฀ their children to the posyandu by way of tokens of฀appreciation฀as฀an฀incentive฀for฀parents฀who฀ take their children to posyandu ฀routinely,฀and฀ penalties฀for฀those฀who฀never฀attend฀posyandu excluding฀them฀from฀receiving฀the฀other฀beneits฀ from฀the฀programme.฀Ibu฀Ina฀36฀years฀old฀has฀ six฀children฀and฀takes฀them฀to฀be฀immunized฀ at the posyandu free of charge. She also has a Jamkesmas community health insurance scheme฀card฀that฀allows฀her฀to฀receive฀free฀ medication at the puskesmas .฀Ibu฀Ana฀47฀years฀ old,฀who฀has฀four฀children,฀had฀her฀babies฀ delivered฀in฀the฀puskesmas and her children were immunized฀there฀as฀well. Source:฀Case฀study฀in฀North฀Jakarta฀and฀East฀ Sumba,฀June–August฀2010 2010. As part of RISKESDAS 2010 Basic Health Research survey, two indicators regarding maternal health status were monitored: the proportion of deliveries attended by professional birth attendants and the level of contraceptive use among couples of reproductive age 15–49 years old. During 2005–2010, the national average rate of births attended by a professional birth attendant was 82.2 per cent. However, in 20 provinces about 60 per cent of the country’s 33 provinces the rates were below this national average. The lowest proportion was found in North Maluku Province 26.6 per cent and the highest proportion was in DI Yogyakarta Province 98.6 per cent. East Nusa Tenggara Province was the eleventh lowest ranked province 64.2 per cent, while DKI Jakarta Province was the fourth highest ranked 95.8 per cent. Although DKI Jakarta had the fourth highest ranking, women from poor families still preferred to give birth with the assistance of a nearby traditional birth attendant. The main reasons for this were the cheaper cost IDR400,000–700,000 for the services of a traditional birth attendant compared with a midwife IDR800,000–900,000, 100 and the option to pay by installments. Women from poor families also rarely attended a puskesmas for routine check-ups regarding contraceptive use. They did not want to wait in queues and faced difficulty attending due to child care commitments andor their existing workloads. Almost all poor families in North Jakarta had more than two children, with most having three to seven children. Mothers from poor families in East Sumba experienced improving conditions between 2005 and 2010 due to the multi-stakeholder programmes implemented by the local government, e.g., the Jamkesmas programme and the Nation Programme for Community Empowerment ‘PNPM Generasi’, which provided: 1 tetanus toxoid immunization to pregnant women and reproductive aged women who intended to become pregnant; 2 free monthly antenatal checkups and a financial incentive of IDR 5,000 for each visit to a health facility, with the target of 3,350 pregnant women; 3 free childbirth services and the provision of up to IDR50,000 in transportation costs for both the pregnant woman and a companion midwife traditional birth attendantfamily member to travel to a health-care facility for safe delivery, with a target of 2,500 births; 4 two free post- partum examinations when the infant is aged 0–1 month and again when aged 28–40 days; 5 complete immunization free of charge; and 6 revitalization of posyandu. Those programmes had a positive impact on reducing maternal mortality rates in the district. The number of maternal deaths recorded was five in 2010 compared to 10 in 2009, 14 in 2008, and 30–50 cases annually in previous years.

3.4.5 Reducing child mortality and maternal

mortality with nutrition supplementation for mothers and children Government intervention for improved child nutrition begins in the womb, with nutritional supplements for pregnant women. The government programme of iron supplementation twice a year February and August was aimed at reducing the prevalence of pregnant women with iron deficiency to 40 per cent 2009 target, with 85 per cent of pregnant mothers receiving any iron supplementation 2014 target. Based on RISKESDAS 2010 data, the percentage of pregnant mothers aged 10–49 years old who consume iron supplements in Indonesia was 80.7 per cent, but only 18 per cent of them consumed the supplements for more than 90 days during pregnancy Figure 3.12 – this percentage is far from the target of 85 per cent. Women in urban areas and those from wealthier households are more likely to consume iron tablets for more than 90 days during pregnancy. Giving solid foods to infants under the age of six months also contributes to malnutrition. Exclusive and continued breastfeeding as well as optimal complementary feeding practices are among the top three most effective interventions for reducing child mortality and under-nutrition Jones et al., 2003 and Bhutta et al., 2008. Between 2002 and 2007 exclusive breastfeeding declined from 40 to 32.4 per cent Figure 3.13 with milk other than breast milk generally being introduced before six months. In 2007 only 41.2 per cent of children 6–23 months old are fed according to WHO recommendations Figures 3.13 and 3.14. The data show that more children from rich households and living in urban areas are fed with the recommended complementary foods Table 3.18. If we compare exclusive breastfeeding practices between urban and rural areas, and by household expenditures wealth quintile, Figure 3.11: Indonesia’s maternal mortality rate, 1990–2015 Maternal death per 100,000 live births 1990-19941993-19971998-20022003-2007 2009 2014 2015 RPJM Target 390 334 307 228 226 118 102 MDGs Target 500 400 300 200 100 Source:฀IDHS฀1994–2007 101 the RISKESDAS 2010 data show that exclusive breastfeeding was more commonly practiced in rural areas than in urban ones, and fewer babies were exclusively breastfed in richer households than in the poorer ones see Figure 3.15. More women working outside the home and longer women’s working hours contributed to the lower prevalence of breastfeeding among the urban and richer households. As also shown in Figure 3.15, boys were more likely to be breastfed than girls. In North Jakarta, many infants aged 0–6 months were not exclusively breastfed and many babies aged over four months received solid foods due to tradition. Mothers believe that giving solid foods, such as bananas, to their children will make them less fussy and less likely to cry. In addition to giving solid food, formula milk was commonly given to complement breast milk. Work demands on mothers were also a reason for not breastfeeding. In fact, posyandu personnel advised mothers to exclusively breastfeed their children and explained how important breast milk is for child development. A low level of exclusive breastfeeding was also found in East Sumba. Vitamin A consumption among children aged 6–59 months is important because it prevents blindness, Vitamin A deficiency, other nutritional problems, and death. In the MoH Strategic Plan 2010–2014 the government set a target for 85 per cent of children aged 6–59 months to be taking Vitamin A capsules by 2014. Data from RISKESDAS 2007 indicated that 71.5 per cent of children aged 6–59 months received Vitamin A capsules, and this figure decreased in 2010 to 69.8 Table 3.18: Coverage of nutrition intervention by urbanrural location and household expenditure, 2007 and 2010 Indonesia Urban Rural Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Households having sufficient iodized salt consumption, 2007 62.3 70.4 56.3 56.7 59.3 61.8 64.1 70.0 Children aged 6–59 months received Vitamin A, 2010 69.8 74.0 65.3 63.8 69.4 73.1 72.3 73.3 Mothers received iron tablet distribution, 2010 18.0 20.3 15.6 12.8 16.2 18.7 21.0 25.1 Children aged 6–23 months with 3 IYCF practices, 2007 41.2 44.7 38.7 36.5 40.7 42.1 42.5 44.4 Source:฀RISKESDAS฀2007฀and฀2010;฀IDHS฀2007 Note:฀IYCF,฀infant฀and฀young฀child฀feeding per cent Figure 3.12. Children who live in urban areas and come from rich households consume more Vitamin A than those who live in rural areas and come from poor households. Between the two case study areas there were obvious differences in terms of nutrition, with cases of malnutrition being more common in East Sumba than in North Jakarta. Causes of malnutrition in both regions differed, but the basic cause was poverty – the prevalence rates of all nutritional problems were higher in poor families. In North Jakarta, household economic difficulties forced mothers to work. As a result, exclusive breastfeeding was not possible for babies and older children had to buy food outside the home, making them susceptible to illness since the purchased foods generally did not meet standards of good nutrition and hygiene. Usually such food consisted of tofu, tempe,฀perkedel, vegetables, salty fish, soy sauce and crackers. Insufficient food, since these children generally only eat once or twice a day, also contributes to child malnutrition. In East Sumba poverty also affected the food consumption patterns of children. The limited economic resources of families made it difficult to provide nutritious food. Children usually ate twice or three times a day but they rarely ate healthy food. A typical child’s breakfast consisted of rice mixed with salt commonly called plain rice, raw chili, and sometimes sweet tea or coffee, and lunch was rice and vegetables.