POLICY CHALLENGES: IMPROVING HEALTH SERVICES AND CARE IN THE DECENTRALISED ENVIRONMENT

THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 62 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 63 midwives from 40.7 per cent in 1992 to 66.3 per cent in 2002 and 73 per cent in 2007 Figure 3.1.20. However, these igures are still some way from reaching the GoI target of 90 per cent of births assisted by skilled personnel. 28 Although it is beyond the remit of this work to provide the reader with a comprehensive explanatory analysis of disparities in Indonesia across all health indicators, nevertheless, by focusing on key health indicators, it is evident that a series of structural i.e., developmental, geographic and economic factors, social and culturalbehavioural factors discussed in later sections of this report all contribute to the production and reproduction of disparities. One important aspect is the provision of services and the readiness of the population to use those health facilities which are likely to play a critical role in reducing the MMR, IMR and U5MR. Critical services, with regards to these key indicators, include antenatal care discussed previously, birth delivery assistance, postnatal care and immunization programmes. Unsurprisingly, there are some notable differences in the use and availability of these services. For instance, at a national level 46 per cent of births take place at a health facility. At the province level, this ranges from 91 per cent in Bali to just 8 per cent in Southeast Sulawesi, according to 2007 IDHS data. A clear pattern of inter-provincial disparities emerges from the data with only four of Indonesia’s 33 provinces achieving the government target of providing 90 per cent of births with skilled assistance. Figure 3.1.20: Percentage of assisted births, Indonesia 2002-2007 Source: IDHS 2002-2003 and 2007 Figure 3.1.21: Percentage of births assisted by skilled providers most qualified persons, Indonesia 2007 Source: IDHS 2007 28 BPS - Statistics Indonesia and Macro International, Indonesia Demographic and Health Surveys IDHS 1991, 2002-2003 and 2007 On the whole, the more rural provinces and particularly those in eastern Indonesia are the least likely to use the assistance of skilled health personnel at childbirth. Furthermore, many of the same provinces with high infant mortality rates are those that have the lowest proportions of births assisted by skilled health personnel. As would be expected, data on assisted birthdelivery confirms the existence of ruralurban disparities, but more detailed data from the National Socio- Economic Surveys SUSENAS 2000-2009, BPS - Statistics Indonesia and from the Ministry of Health 2007 Riskesdas, Basic Health Research provide some further insights. Data from the National Socio-Economic Survey Figure 3.1.22 indicate that the ruralurban gap decreased between 2000 and 2004 from a gap of 31.7 per cent in 2000 improving to an all-time best of 24.8 per cent in 2004, but has remained consistent since then at approximately 25 per cent. Furthermore, in a study in the Serang and Pandeglang districts in Banten province on Java, as cited in National Development Planning Board BAPPENAS and Ministry of Health’s The Landscape Analysis, Makowiecka et al. 2009 found a higher density of midwives working in urban areas as compared to remote areas, and also found that those assigned to remote areas were less experienced and managed fewer births, compromising their capacity to maintain professional skills. 29 Furthermore, 2007 IDHS data indicates that in those provinces where there are lower rates of skilled birth attendance, there is a preference for the use of traditional birth attendants dukun bayi. For example, traditional birth attendants were commonly used in Maluku 67.5 per cent, West Sulawesi 63.2 per cent, Southeast Sulawesi 67.3 per cent, Gorantalo 69.6 per cent, Banten 52.1 per cent and Bengkulu 50.6 per cent, amongst others. These results indicate issues of preference for traditional birth methods, as well as problems of coverage of skilled birth attendants. Figure 3.1.22: Percentage of women with children under age five who used trained health personnel during their most recent delivery by area, Indonesia 2000-2008 Source: BPS - Statistics Indonesia, Welfare Statistics based on National Socio-Economic Surveys 2000-2008 Figure 3.1.23 from 2007 Riskesdas data sheds further light on the nature of the delivery assistance which rural and urban women use. 30 Very few rural women give birth with the assistance of qualified health professional. Only 2.6 per cent of rural women give birth with the assistance of a doctor, and while a significantly larger proportion of rural women give birth assisted by a midwife 32.9 per cent this figure is still only about half that of urban women 61.7 per cent. It is also in rural areas that women are more likely to use traditional birth attendants and infant mortality rates are higher, particularly amongst poorer groups. 29 BAPPENAS National Development Planning BoardIndonesian Ministry of Health 2010 The landscape analysis: Indonesian country assessment , BAPPENAS: Jakarta, p61 30 Ministry of Health 2008 Laporan Nasional, Riset Kesehatan Dasar Riskesdas 2007, National Institute of Health Research and Development: Jakarta Jambi Papua W est Papua W est Sumatra W est Kalimantan Riau Riau Islands East kalimantan Banten Bangka Belitung Central Kalimantan Bali W est Java Maluku Gorontal o East Nusa T enggar a W est Nusa T enggar a Nanggroe Aceh D Lampung Central Sulawesi Southeast Sulawesi Bengkul u Central Java D.I. Y ogyakarta East Java South Sumatra South Kalimantan D.K.I Jakarta North Sumatra North Maluku North Sulawesi South Sulawesi W est Sulawesi Indonesi a 120.0 100.0 80.0 60.0 40.0 32. 8 46. 2 46. 3 72. 5 73. 83. 97. 3 20.0 0.0 Per cent Per cent 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 66.3 73.0 31.5 24.0 IDHS 2002-2003 IDHS 2007 IDHS 2002-2003 IDHS 2007 Skilled provider Traditional Birth Attendant Per cent 100.00 81.5 83.5 83.8 85.7 85.8 84.8 87.2 88.7 88.2 62.9 60.6 49.8 50.7 53.7 55.4 61.0 59.3 61.0 2000 2001 2002 2003 2004 Year 2005 2006 2007 2008 80.00 60.00 40.00 20.00 0.00 Urban Rural THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 64 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 65 Figure 3.1.23: Percentage of mothers with assisted childbirths, most recent birth by area and type of assistance, Indonesia 2007 Source: Ministry of Health, Riskesdas 2007 Figure 3.1.24: Percentage of births assisted by skilled providers, by wealth quintile, Indonesia 2007 Source: IDHS 2007 Figure 3.1.25: Percentage of mothers with assisted childbirths, most recent birth by wealth quintile, Indonesia 2007 Source: Riskesdas 2007 Figures 3.1.24 and 3.1.25 provide some information relating to assisted delivery. Figure 3.1.24, showing IDHS data, indicates relatively high proportions of deliveries assisted by skilled health personnel across the wealth quintiles in Indonesia. However, while the rates range from 79.2 per cent to 86.4 per cent across the four wealthiest quintiles, the least wealthy quintile lags far behind, at only 65 per cent of the women’s most recent deliveries. The more detailed data from the 2007 Riskesdas regarding the nature of the assistance provided during delivery shows a distinct set of disparities across the social strata Figure 3.1.25. Birth assistance provided by doctors remains low throughout Indonesian society, ranging from 2.9 per cent amongst the poorest and just under 70.0 13.6 2.6 1.4 1.8 61.7 32.9 18.7 43.7 4.0 16.9 0.7 2.2 Doctor Midwife Other paramedic Traditional Birth Attendant Family Other 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Urban Rural 100.0 65.0 79.2 82.8 86.5 86.4 4.7 2.3 1.4 0.3 0.2 80.0 60.0 40.0 20.0 0.0 Traditional Birth Attendant Skilled provider lowest Second Middle Fout h Highest 10 per cent amongst the wealthiest. Midwives are clearly an important source of skilled support, being the main source of assistance for the two highest quintiles of society. In contrast, traditional birth attendants remain the main source of support for the three poorest quintiles, and in the provinces with the lowest rates of skilled birth attendance. Additional data based on the 2005 Intercensal Survey SUPAS underline wealth-based inequalities, including the estimate that 83 per cent of women in the highest wealth quintile give birth at a health facility whilst only 14 per cent of women in the lowest quintile do so. To measure the achievement towards MDGs, health experts have argued that the proportion of births attended by skilled health attendants is not as closely associated with maternal death as much as the capacity to manage the direct causes of maternal death. Interventions addressing maternal death should be implemented both through providing skilled assistance and creating an ‘enabling environment’ for managing cases of post-partum haemorrhage, severe infections, eclampsia, prolonged labour and also abortion complications, as well as known cases of obstetric emergencies or complications. 31 Furthermore, WHO 2006 demonstrates that maternal mortality remains high in countries where a large proportion of health professionals are not able to manage obstetric emergencies either due to lack of training or lack of an ‘enabling environment’ and where referral systems do not facilitate timely life-saving interventions. 32 Other research indicates that assisted births in hospitals and other health-care institutions are likely to reduce maternal and infant mortality associated with complicated deliveries. Such findings seem relevant for explaining, at least in part, the only marginal decreases in infant and maternal mortality rates. Facility-based delivery is incredibly important for decreasing deaths from complicated births, but there has been little change in use of health facilities for delivery during the same time period when decline in infant and maternal mortality rates have been stagnating in Indonesia. Figures 3.1.26, 3.1.27 and 3.1.28 demonstrate that the number of births in public health-care facilities has changed little between 2002-2003 and 2007, but births in private health facilities have increased and births in the home have decreased slightly. While many of the figures mentioned earlier indicated an aggregate increase in the uptake of assisted births by skilled professionals in recent years, this has not been accompanied by significant reductions in infant and maternal mortality rates. At the same time, there has not been a similar uptake of using public health-care facilities for assisted births. Therefore, the marginal change in mortality rates over time may also be related to the underutilization of health-care facilities for delivery. Furthermore, the number of births at home in rural areas has only decreased marginally compared to urban areas, with very little difference in the use of public health facilities for assisted births in both urban and rural populations - in rural areas in particular mortality rates remain high. Urban populations tend to be less likely in 2007 to give birth at home, tending to be using private health facilities. The breakdown of the 2007 Riskesdas data demonstrates that as wealth increases, so too does the likelihood of using private health providers instead of giving birth in the home, but that there is very little difference by wealth quintile on the use of public facilities, with the poorest quintiles being least likely to use public or private health facilities see Figure 3.1.28. 60.0 50.0 40.0 Quintile 1 Quintile 2 Quintile 3 Wealth Quintile Quintile 4 Quintile 5 30.0 20.0 10.0 0.0 2.9 30. 4 1.9 44. 5 18. 2.3 35. 9 3.1 1.0 42. 2 16. 2 1.6 4.9 38. 4 38. 9 13. 9 2.2 6.0 44. 36. 6 10. 2 0.9 9.9 52. 5 27. 7 1.5 6.9 1.4 2.9 Per cent Per cent Per cent 31 Bailey, P., Paxton, A., Lobis, S. and Fry, D. 2006 ‘Measuring progress towards the MDG for maternal health: Including a measure of the health system’s capacity to treat obstetric complications’, International Journal of Gynaecology and Obstetrics , Vol.93: 292-299 32 WHO 2006 Making a difference in countries THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 66 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 67 Figure 3.1.26: Percentage births by place of delivery, Indonesia 2002-2007 Source: IDHS 2002-2003 and 2007 Figure 3.1.27: Percentage births by place of delivery and by area, Indonesia 2002-2007 Source: IDHS 2002-2003 and 2007 Figure 3.1.28: Percentage of births by place of delivery and by wealth quintile, Indonesia 2007 Source: IDHS 2007 Overall, it is clear that public services for assisted births by skilled personnel for the rural poor are either not accessible or are underutilized. This may have some bearing on higher IMR and MMR for these populations. These results also indicate that improving the enabling environment and improving access to and the use of public health-care facilities for assisted births may be key to reducing mortality rates and to achieving the GoI goal in the ‘Making Pregnancy Safer’ strategy that every obstetric and neonatal complication should be managed adequately. 3.1.3.3 Postnatal care Postnatal care PNC is important for the welfare of both mother and child. It provides an opportunity to treat complications arising from the delivery, and provides the mother with important information on how to care for herself and her infant. The postnatal period is defined as the time between delivery of the placenta and 42 days six weeks following delivery. The timing of postnatal care is important because the first two days after delivery are critical; most maternal and neonatal deaths occur during this period. The following figures on PNC demonstrate that there has only been a very slight increase over time. Marked provincial disparities also exist. While the majority of provinces have rates of PNC exceeding 60 per cent, there is almost universal coverage in Yogyakarta for example, but only 34 per cent of women in Papua receive PNC Figure 3.1.31. Disparities also exist among in terms of wealth, whereby approximately 90 per cent of pregnant women in the highest three wealth quintiles receive PNC, but poorer women lag far behind. While inter-provincial and wealth disparities exist, disparities are less pronounced between urban and rural areas with similar levels of care. Figure 3.1.31: Percentage of post-partum women with postnatal care by province, Indonesia 2007 Source: IDHS 2007 Figure 3.1.29: Percentage of post-partum women with postnatal care, Indonesia 2002-2007 Source: IDHS 2002-2003 and 2007 Figure 3.1.30: Percentage of post-partum women with postnatal care by area, Indonesia 2002-2007 Source: IDHS 2002-2003 and 2007 84.0 83.0 82.5 83.6 82.0 81.0 IDHS 2002-2003 IDHS 2007 Per cent 40.0 50.0 60.0 70.0 80.0 90.0 Urban Rural IDHS 2002-2003 IDHS 2007 83. 7 81. 9 85. 5 83. Per cent 120.0 100.0 80.0 34 76 78 84 93 98 60.0 40.0 20.0 0.0 W est Java Lampung Central Sulawesi D.I. Y ogyakarta Central Java Jambi Papua W est Papua W est Sumatra W est Kalimantan Riau Riau Islands East kalimantan Banten Bangka Belitung Central Kalimantan Bali Maluku Gorontal o East Nusa T enggar a W est Nusa T enggar a Nanggroe Aceh D Southeast Sulawesi Bengkul u East Java South Sumatra South Kalimantan D.K.I Jakarta North Sumatra North Maluku North Sulawesi South Sulawesi W est Sulawesi Indonesi a 60.0 70.0 50.0 40.0 30.0 20.0 10.0 0.0 Percentage IDHS 2002-2003 IDHS 2007 Health facility public sector Health facility private sector Place of Delivery Home 9.7 36.4 52.7 9.2 30.5 59.0 -5.00 5.00 15.00 25.00 35.00 45.00 55.00 65.00 75.00 85.00 95.00 13. 1 46. 5 39. 5 5.9 16. 6 76. 1 12. 9 57. 4 7.4 21. 5 69. 6 28. 6 Percentage Health facility public sector Health facility Private sector Home IDHS 2002-2003 IDHS 2007 Urban Rural Urban Rural -5.00 5.00 15.00 25.00 5.2 8.3 11. 4 12. 2 12. 4 8.4 23. 4 36. 5 49. 5 71. 84. 8 66. 8 51. 1 37. 1 15. 5 35.00 45.00 55.00 65.00 75.00 85.00 95.00 Percentage Lowest Second Middle Fourth Higest Health facility public sector Health facility Private sector Home THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 68 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 69 Figure 3.1.32: Percentage of post-partum women with postnatal care by wealth quintile, Indonesia 2007 Source: IDHS 2007

3.1.4 MALNUTRITION

Nutrition status is a key outcome and indicator of the state of child welfare. As was illustrated by the conceptual framework on the determinants of child mortality and nutritional status earlier in this section Figure 3.1.1, for children to grow adequately, or for adults to have an adequate nutritional status, several conditions must be met. Their dietary intake and their health status - which act in synergy - are the immediate determinants of their nutritional status. Dietary intake in turn, will be affected by the food available and accessible to the household or its food security, while health status will depend on the access to health services as well as to safe water and appropriate sanitation. Food security, access to care, as well as health status result themselves from determinants operating at the underlying level of their family and community as well as at the more fundamental levels of society. They relate to the availability and control of human, economic and organisational resources in the society, themselves the results of previous and current technical and social conditions of production, together with political, economic and ideological-cultural factors. Malnutrition is often seen amongst the poorest segments of the population. 33 Malnutrition is a generic terms that refers to undernutrition and overnutrition. In this report, only undernutrition will be covered. Undernutrition means being underweight for one’s age, too stunted or short for one’s age, and wasted or thin for one’s height. Undernutrition also refers to being deficient in vitamins and minerals micronutrient malnutrition. 34 Undernutrition is associated with 60 per cent of deaths among children under five years of age. 35 The impacts of undernutrition are enormous. Malnutrition erodes human capital by impairment of cognitive and physical development. It leads to lower productivity and wage return in adulthood. It also affects the chances of a child going to and staying in school, and learning well. Malnutrition is associated with maternal health and mortality and it increases the risks associated with HIV and tuberculosis, compromises treatment, and hastens the onset of AIDS. 36 Unequivocally, undernutrition remains a key issue in Indonesia. Indonesia currently ranks fifth in the world in terms of number of stunted children. Although over the last decades, the number 33 Gwatkin, D. R., Rutstein S., Johnson K., Suliman, E., Wagstaff, A., Amouzou, A. 2007 Socio-economic differences in health, nutrition and population within developing countries , World BankGovernment of the Netherlands Swedish International Development Cooperation Agency 34 UNICEF 2006 Undernutrition, available at: http:www.unicef.orgprogressforchildren2006n4undernutritiondefinition.html Last accessed 22 February 2011 35 Pelletier D. L., Frongillo E. A. Jr., Habicht J-P. 1993 ‘Epidemiologic evidence for a potentiating effect of malnutrition on child mortality’, American Journal of Public Health , Vol.83: 1130-1133 36 World Bank 2006 Repositioning nutrition as central to development: A strategy for large-scale action, World Bank: Washington, D.C. of underweight children has been reduced, 18 per cent of Indonesian children remain affected based on 2007 data Figure 3.1.33. Data on the prevalence of stunting 36.8 per cent and wasting 13.6 per cent among Indonesian children 0-59 months under-fives indicate high public health problems as per WHO deinitions and cut-offs stunting 40 per cent, wasting 10 per cent. 37 Child stunting is widely accepted as one of the best predictors of the quality of human capital, influencing potential academic performance and future earning capability of a nation. 38 Related data from the Riskesdas 2007 are shown in Figures 3.1.33 through 3.1.41. Once again, aggregate national indicators are complemented by disparity indicators wherever the data are available. Figure 3.1.33: Percentage of children under five suffering from wasting, stunting and underweight, Indonesia 2007 Source: Riskesdas 2007 Riskesdas 2007 data Figure 3.1.34 shows that the prevalence of undernutrition is higher in rural areas. It is likely that access to food, appropriate care and to a healthy environment and health services is less than in urban area thus, impacting on child nutritional status. Poverty likely constitutes one of the major basic causes of undernutrition, with the poorest quintiles being the most likely to suffer from stunting, wasting, and to be underweight Figure 3.1.36 - 3.1.38. Although, further research needs to be undertaken into why there is less difference between wealth quintiles in regards to wasting when compared with stunting and children being classified as underweight. In Indonesia, such problems are also compounded by, inadequate care, gender inequality, poor health services, and environmental degradation. 39 The prevalence of undernutrition is also higher amongst boys Figure 3.1.35. Data from regional assessment 40 as well as some international studies Caputo et al. 2003 41 ; and Svedberg et al. 1996 42 have shown a similar pattern. Because girls represent an asset for the future of household farming activities, they might have been prioritised in terms of care practices and, in particular, in regards to feeding practices. 37 WHO 1995 Physical status: The use and interpretation of anthropometry, Technical report series, Report of the WHO Expert Committee No. 854: Geneva, Switzerland, available at: http:www.who.intchildgrowthpublicationsphysical_statusenindex.html Last accessed 17 June 2010 38 Victora, C. G., Adair, L., Fall, C., Hallal, P. C., Martorell, M., Richter, L., Sachdev, H. S., for the Maternal and Child Undernutrition Study Group 2008 ‘Maternal and child undernutrition: Consequences for adult health and human capital’, The Lancet, Vol.37: 340-357 39 Setboonsarng, S. 2005 ‘Child malnutrition as a poverty indicator: An evaluation in the context of different development interventions in Indonesia’, Asian Development Bank Institute Discussion Paper No. 21, available at: http:www.adbi.orgdiscussion- paper20050114869.malnutrition.poverty.indonesiadata.sources.on.child.malnutrition.in.indonesia Last accessed 6 October 2010 40 Government of IndonesiaWFPUNICEFFAO 2010 Nutrition security and food security in seven districts in NTT province, Indonesia: Status, causes and recommendations for response , Government of Indonesia: Jakarta 41 Caputo, A., Foraita, R., Klasen, S., Pigeot, I., 2003 ‘Undernutrition in Benin - An analysis based on graphical models’, Social Science and Medicine Vol.568: 1677 42 Svedberg, P. 1996 ‘Gender bias in Sub-Saharan Africa: Reply and further evidence’, Journal of Development Studies, Vol.32: 933 Wealth Quintile Per cent 70.0 75.0 80.0 85.0 90.0 95.0 77.3 82.9 89.2 90.2 89.3 Lowest Second Middle Fourth Higest Wasting Stunting Percentage Moderate Underweight 7.4 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 7.4 18.0 13.0 5.4 18.8 Severe THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 70 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 71 Figure 3.1.34: Percentage of children under five suffering from wasting, stunting and underweight by area, Indonesia 2007 Source: Riskesdas 2007 Figure 3.1.35: Percentage of children under five suffering from stunting, wasting and underweight by sex, Indonesia 2007 Source: Riskesdas 2007 Figure 3.1.37: Percentage of children under five suffering from wasting by expenditure per capita per month, Indonesia 2007 Source: Riskesdas 2007 Figure 3.1.36: Percentage of children under five suffering from stunting by expenditure per capita per month, Indonesia 2007 Source: Riskesdas 2007 Quintile 5 Quintile 4 Quintile 3 Quintile 2 Quintile 1 0.0 5.0 10.0 15.0 20.0 Moderate Severe 7.0 6.0 7.1 5.9 7.3 6.1 7.7 6.2 7.9 6.8 Figure 3.1.38: Percentage of children under five suffering from being underweight by expenditure per capita per month, Indonesia 2007 Source: Riskesdas 2007 As shown in Figures 3.1.39, 3.1.40 and 3.1.41, East Nusa Tenggara, Central Sulawesi, Maluku, South Kalimantan, Aceh, and Gorontalo are the provinces where the rates of underweight and stunted children are highest, and well above the national average. Wasting is high in East Nusa Tenggara, Riau, Jambi, and Aceh. The link between the poverty levels of each province and the prevalence of undernutrition needs to be highlighted. Aceh, for instance, despite a wealth of natural resources, has high levels of poverty and undernutrition, as well as a lower human development index HDI. Figure 3.1.39: Percentage of children under five who are underweight by province, Indonesia 2007 Source: Riskesdas 2007 Figure 3.1.40: Percentage of children under five with stunting by province, Indonesia 2007 Source: Riskesdas 2007 Per cent Quintile 5 Quintile 4 Quintile 3 Quintile 2 Quintile 1 10.0 20.0 30.0 Moderate Severe 9.6 4.1 11.8 4.7 12.9 5.2 7.7 5.7 15.4 6.7 D.I. Y ogyakarta W est Papua Riau Islands Central Kalimantan Bali Maluku Gorontal o East Nusa T enggar a W est Nusa T enggar a Nanggroe Aceh D South Sumatra South Kalimantan D.K.I Jakarta North Sumatra North Maluku South Sulawesi Central Sulawesi W est Sulawesi W est Java Lampung Central Java Jambi Papua W est Sumatra W est Kalimantan Riau East kalimantan Banten Bangka Belitung Southeast Sulawesi Bengkul u East Java North Sulawesi Indonesi a 35.0 40.0 45.0 50.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Moderate Severe 13. 12. 7 13. 4 13. 7 18. 6 18. 8 20. 2 24. 2 22. 5 17. 7 26. 9 18. 17. 4 17. 8 Per cent W est Java Lampung D.I. Y ogyakarta Central Java Jambi Papua W est Papua W est Sumatra W est Kalimantan Riau Riau Islands East kalimantan Banten Bangka Belitung Central Kalimantan Bali Maluku Gorontal o East Nusa T enggar a W est Nusa T enggar a Nanggroe Aceh D Southeast Sulawesi Bengkul u East Java South Sumatra South Kalimantan D.K.I Jakarta North Sumatra North Maluku North Sulawesi South Sulawesi Central Sulawesi W est Sulawesi Indonesi a Per cent 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 9.4 10. 7 6.6 5.4 14. 6 13. 8.2 3.2 8.5 2.4 4.0 12. 15. 8 24. 2 Moderate Severe W astin g Stuntin g Per cent Unde r- weight Rural Urban Rural Urban Rural Urban 20.9 19.0 16.0 6.4 6.7 7.4 7.5 5.6 4.2 0.0 20.0 40.0 60.0 11.7 14.0 16.7 Severe Moderate Per cent W astin g Stuntin g Unde r- weight 0.0 20.0 10.0 30.0 40.0 Severe Moderate Females Males Females Males Females Males 5.8 7.3 6.6 17.9 17.9 19.6 18.1 5.0 12.7 5.8 13.3 7.6 Per cent Quintile 5 Quintile 4 Quintile 3 Quintile 2 Quintile 1 0.0 20.0 40.0 60.0 Moderate Severe 15.1 15.2 17.1 17.0 18.5 18.8 19.0 19.9 19.2 21.3 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 72 THE SITUATION OF CHILDREN AND WOMEN IN INDONESIA 2000-2010 73 Figure 3.1.41: Percentage of children under five with wasting by province, Indonesia 2007 Source: Riskesdas 2007 Maternal nutrition is also of concern. Riskesdas 2007 data indicate that 14 per cent of women have chronic energy deiciency mid-upper arm circumference 23.5 cm. According to WHO 43 , a prevalence rate between 10-19 per cent is considered to be medium prevalence, indicating a poor nutrition situation. Riskesdas 2007 data shows that in general urban areas 20 per cent of women of reproductive are anaemic, and 25 per cent are anaemic in pregnancy. Maternal undernutrition increases the risk of low birthweight see next subsection. Low birthweight is associated with a higher risk of mortality and childhood undernutrition and, in particular with stunting. Given the situation, reducing undernutrition is a top priority for the Government of Indonesia, as emphasised in the 2010-2014 RPJMN. 44

3.1.5 LOW BIRTHWEIGHT

A low birthweight is strongly associated with increased risk of death for children. Research at the global level indicates that infants born at term weighing 1,500-1,999 grams are eight times more likely to die during the neonatal period. 45 Children weighing between 2,000 and 2,499 grams are three times more likely to die from all causes during the neonatal period compared to those weighing at least 2,500 grams at birth. 46 It is important to stress that a low birthweight alone is rarely a direct cause of death, but rather an indirect cause of neonatal deaths, particularly in cases of death from asphyxia and infection sepsis, pneumonia and diarrhoea, which together account for about 60-80 per cent of neonatal deaths. 47 Children with low birthweight are also more likely to be stunted in early childhood. 48 The IDHS data presented in Figure 3.1.42 indicate that the incidence of low birthweight in Indonesia is 5.5 per cent, and that the rate did not reduce significantly between 2002-2003 and 2007. The 2007 IDHS did not provide birthweight data by province. Riskesdas 2007 data on birthweight, however, indicated a higher incidence of low 43 WHO 1995 Physical status: The use and interpretation of anthropometry 44 Government of Indonesia 2010 National medium-term development plan RPJMN 2010-2014, Government of Indonesia: Jakarta 45 Black, R. E., Allen, L. H., Bhutta, Z. A, Caulield, L. E., de Onis, M., Ezzati, M., Mathers, C. and Rivera, R. for the Maternal and Child Undernutrition Study Group 2008, ‘Maternal and child undernutrition: Global and regional exposures and health consequences’, The Lancet , Vol. 371:243-260 46 Ibid. 47 Thapar, N. and Sanderson, I. R. 2004 Diarrhoea in children: an interface between developing and developed countries, University of London: London 48 Victora, C. G., de Onis, M., Hallal, P. C., Blossner, M., Shrimpton, R. 2010 ‘Worldwide time of growth faltering: Revisiting implications for intervention’, Pediatrics, published online D.I. Y ogyakarta W est Papua Riau Islands Central Kalimantan Bali Maluku Gorontal o East Nusa T enggar a W est Nusa T enggar a Nanggroe Aceh D South Sumatra South Kalimantan D.K.I Jakarta North Sumatra North Maluku South Sulawesi Central Sulawesi W est Sulawesi W est Java Lampung Central Java Jambi Papua W est Sumatra W est Kalimantan Riau East kalimantan Banten Bangka Belitung Southeast Sulawesi Bengkul u East Java North Sulawesi Indonesi a 20.0 15.0 10.0 5.0 0.0 Moderate Severe 12. 2 9.9 9.5 9.2 9.1 6.2 5.4 7.0 4.7 3.6 5.4 5.2 3.8 7.1 7.4 10. 5 birthweight for the same year, placing it at 11.5 per cent. 49 Figure 3.1.43, based on 2007 Riskesdas data, gives a clear picture of the disparity among provinces, indicating that the incidence of low birthweight at the provincial level ranges from 5.8 per cent in Bali to 27 per cent in Papua. Fifteen of the 33 Indonesian provinces perform worse than the national average of 11.5 per cent, with over 20 per cent of children born with low birthweight in three provinces Papua, West Papua and East Nusa Tenggara. Figure 3.1.42: Incidence of low birthweight percentage, Indonesia 1992-2007 Source: IDHS 1991-1997, 2002-2003 and 2007 Note: In accordance with WHO recommendations, a low birthweight is defined as children born at term weighing 2,500 grams Figure 3.1.43: Percentage of infants with low birthweight by province, Indonesia 2007 Source: Riskesdas 2007 Figure 3.1.44: Percentage of infants with low birthweight by area, sex, and expenditure per capita, Indonesia 2007 Source: Riskesdas 2007 49 Ministry of Health 2008 Laporan Nasional, Riset Kesehatan Dasar Riskesdas 2007 D.I. Y ogyakarta W est Papua Riau Islands Central Kalimantan Bali Maluku Gorontal o East Nusa T enggar a W est Nusa T enggar a Nanggroe Aceh D South Sumatra South Kalimantan D.K.I Jakarta North Sumatra North Maluku South Sulawesi Central Sulawesi W est Sulawesi W est Java Lampung Central Java Jambi Papua W est Sumatra W est Kalimantan Riau East kalimantan Banten Bangka Belitung Southeast Sulawesi Bengkul u East Java North Sulawesi Indonesi a Per cent 0.0 5.0 10.0 15.0 20.0 25.0 30.0 27. 20. 3 11. 5 11. 5 9.8 5.8 IDHS 1991 2.6 3.4 4.7 5.6 5.5 IDHS 1994 IDHS 1997 IDHS 2007 IDHS 2002-2003 Percent 1 2 3 4 5 6 Per cent 2 4 6 8 10 12 14 10.8 12.2 10.0 13.0 13.1 10.7 11.9 11.3 10.5 Urban Area Sex Expenditure per capita Rural Male Female Quintile1 Quintile2 Quintile3 Quintile4 Quintile5