Child mortality in all children under the age of 18

97 coverage ranged from a low of 47.4 per cent in Papua to a high of 96.4 per cent in Yogyakarta, with 19 provinces having coverage rates below the national level. Compared to the 2007 levels, only four provinces recorded increased coverage with improvement ranging between 2.5 and 6.8 percentage points Ministry of Health, 2010. The achievement of UCI coverage in Indonesia was still low at 73.8 per cent of children in 2006, 76.1 per cent in 2007, 68.2 per cent in 2008 and 68 per cent in 2007 Figure 3.10. The GoI identified the weaknesses of the national health system and the management of immunization programmes as the causes of the low coverage achievement. Complete immunization consists of one BCG, three DPT, three polio, three Hepatitis B and one measles immunizations. Children who receive incomplete immunizations are referred to as ‘dropouts’. According to RISKESDAS 2007, the percentage of drop-outs was 45.3 per cent compared with 46.2 per cent who received complete immunization Table 3.16. Some barriers to the supply of immunization services were: i changes of vaccination staff juru imunisasi, JURIM who were appointed in the mid-1980s, but then transferred to become midwives; ii regional proliferation, natural disasters, and violent conflicts between communities causing a weakened capacity of institutional arrangements; and iii poor commitment from local governments when it came to prioritizing immunization programmes, as evidenced by inadequate allocation in local budgets and unsupportive local regulations regarding immunization. Further analysis of rates of immunization revealed the persistence of a ruralurban gap Table 3.17. However, mixed results on other variables do not point to any particular determinants associated with incomplete childhood immunization. For complete immunization, the deprivation in urban areas is larger than rural areas whilst for immunization against measles in particular, the deprivation in rural areas is greater than in urban areas. The deprivation with regards to complete immunization was two percentage points higher in urban areas in 2009. The urbanrural gap for measles immunization was wider; around seven percentage points in 2007, increasing to nine percentage points in 2010. Regarding complete immunization, the deprivation was slightly higher among children from households headed by males than by females, which might reflect greater awareness among women regarding the importance of immunization. The size of the households, the educational background of the household head, and the socio-economic status of the households were also associated with differences in the proportions of children receiving complete immunizations and measles immunization. Figure 3.10: Coverage of Universal Child Immunization UCI, 2002–2009 78 76 74 72 70 68 66 64 62 of Children under one year old 2002 2003 2004 2005 2006 2007 2008 2009 74.5 72.5 72.9 76 73.8 76.1 68.2 68 Source:฀MoH฀Decree฀No.฀4822010 Table 3.16: Children aged 12- to 23-months obtaining complete immunizations by respondent characteristics, 2007 National Boys Girls Urban Rural Quintile 1 poorest Quintile 2 Quintile 3 Quintile 4 Quintile 5 wealthiest Complete 46.2 46.6 45.7 54 41.3 41.6 43.4 47.3 49.4 53.5 Incomplete 45.3 45.2 45.4 41.5 47.7 47.1 46.9 44.6 44.5 41 None 8.5 8.2 8.9 4.5 11.1 11.3 9.7 8.1 6.1 5.5 Source:฀Riskesdas฀2007 98 Table 3.17: Children deprived in the health dimension, by household characteristics Gender of household head Female Male Number of household members Less than 3 3–4 5–6 7+ Educational level of household head Nonedid not attend school Finished primary school Finished junior high school Finished senior high school Finished diplomaacademyuniversity Geographical location Urban Rural Household welfare expenditure quintile Q1 Q2 Q3 Q4 Q5 Diarrhoea 2009 1.46 1.68 1.22 1.73 1.58 1.72 1.83 1.65 1.77 1.55 1.24 1.58 1.73 1.92 1.61 1.45 1.77 1.41 Asthma 2009 0.63 0.81 0.85 0.83 0.72 0.9 0.83 0.82 0.95 0.68 0.64 0.74 0.85 0.82 0.77 0.71 0.85 0.84 Incomplete immunization 2009 20.65 25.47 10.74 27.83 23.41 23.17 20.1 24.25 27.95 28.57 27.53 26.28 24.1 25.27 24.48 24.86 25.56 25.48 2007 28.4 21.8 17.7 11.4 6.9 14.0 21.2 21.9 21.5 16.9 15.7 13.2 2010 43.7 30.3 22.5 18.7 14.5 21.4 29.8 35.0 28.6 22.2 19.2 13.7 Self-reported No measles immunization Note:฀The฀immunization฀data฀refers฀only฀to฀children฀12–23฀months฀old Source:฀฀Estimated฀using฀data฀from฀the฀2009฀SUSENAS฀Panel฀and฀Core;฀฀RISKESDAS,฀MoH,฀2010 Other factors that might affect child survival include a lack of access to safe water and proper sanitation, breastfeeding practices and child nutritional conditions in general. As discussed in the previous section, many children still suffer from a lack of access to safe water, sanitation and healthy shelters which has potentially caused hygiene-related diseases. The 2003 and 2009 SUSENAS data indicated an increasing prevalence of diarrhoea, asthma, influenza, coughs and fevers, as well as self- reported work or school disruption due to ill health. Diarrhoea and asthma as well as other acute respiratory infections are among the main causes of infant and under-five mortality see also the discussion in section 3.4.1 of this chapter. As presented in Table 3.17, the prevalence of these diseases is higher among the children of male-headed households, large households, households where the household head has a low level of education, households in rural areas, and poor households. According to SUSENAS, exclusive breastfeeding has been becoming less popular. The data in 2009 shows 67.8 per cent of infants under 6 months were not exclusively breastfed; an increase from 60.5 per cent in 2003. Regarding nutritional conditions, there have been some improvements reflected in the decreasing prevalence of stunting and wasting among children. However, according to RISKESDAS, the prevalence of wasting 13.30 per cent and stunting 35.60 per cent in 2010 remain too high to be ignored in the overall context of child survival see also section 3.4.6 of this chapter.

3.4.4 Maternal mortality

The progress in reducing maternal mortality in Indonesia is still far from the MDG target for 2015 and hence requires special attention Figure 3.11. The quality of antenatal care is not optimal; 61.4 per cent of pregnant women attend at least four antenatal care visits and only 18 per cent took at least 90 doses of iron tablets RISKESDAS 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,