DR - MIKKO REPRODUCTIVE HEALTH AND MATERNAL HEALTH SERVICE PalangkaRaya170312 PDF

REPRODUCTIVE HEALTH AND
MATERNAL HEALTH SERVICE

IN INDONESIA
Biran Affandi
Klinik Raden Saleh

Department of Obstetrics and Gynecology
Faculty of Medicine , University of Indonesia /
Cipto Mangunkusumo General Hospital, Jakarta
Affandi B. Reproductive Health & Maternal Health Service in Indonesia . Palangka Raya Obstetrics & Gynecology Update , 17 March 2012
Objectives:
1. To define Reproductive Health
2. To discuss maternal health
service in Indonesia
3. To overview magnitude of the
problems
4. To discuss ways of solution
Affandi B. Reproductive Health & Maternal Health Service in Indonesia . Palangka Raya Obstetrics & Gynecology Update , 17 March 2012
‘The enjoyment of the highest
attainable standard of health is
one of the fundamental rights
of every human being without
distinction of race, religion,
political belief, economic or
social position’
Constitution of the World Health Organization
Affandi B , Soebijanto S. Reproductive Health ,What is it ? Prepared for Module of Reproduction ,Faculty of Medicine – University of Indonesia , 22 Oct 2007
Reproductive Rights
• Attaining the goals of sustainable, equitable
development requires that individuals are able to
exercise control over their sexual and
reproductive lives:
Reproductive health
Reproductive decision-making
Equality and equity for men and women
Sexual and reproductive security
Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990
‘Health is a state of complete
physical,
mental and social-being
and not merely the absence
of disease or infirmity’
Constitution of the World Health Organization
Definition of reproductive health
“Reproductive health is a state of
complete physical, mental and
social well-being and not merely
the absence of disease or infirmity,
in all matters relating to the
reproductive system and to its
functions and processes.”
Lancet, 2006
Physiology of the
Menstrual Cycle
• Interaction of
hypothalamus,
pituitary gland and the
ovary. Negative and
positive feedback
mechanisms:
Physiology of the Menstrual Cycle
• Number of germ cells in human ovaries:
• Follicle
development (1):
• Primordial
follicles are found
predominantly in
the ovarian cortex.
•
• Follicle development (2):
• Corpus luteum (yellow
body):
-The ruptured follicle develops after the
ovulation into the corpus luteum.
-Cytomorphological sign is the new
vascularization of the previous avascular
granulosa cells.
-Corpus luteum is now connected to the
vessel system and low density lipoprotein
(LDL)-receptors are expressed.
-Thus the granulosa cells can use the offered
cholesterole for the progesterone-
biosynthesis
-Maximum serum progesterone levels 15
ng/ml 6 to 8 days after the ovulation
new vascularization of
granulosa cells
• Endometrial changes:
Endometrium contains: surface epithelium, glandular
epithelium, endometrial stroma, connective tissue
with fibroblasts, macrophages.
Estradiol leads to massive proliferation with increased
mitotic activity of the endometrial cells. Estradiol
binds to estrogen receptor thus inducing
progesterone receptors. Endometrium turns out to
be sensitive for the progesterone effect in the
secretory phase of the cycle (O‘Malley et al. 1991).
Endometrial thickness increases from 1 mm on day 1
up to 7-8 mm on day 14.
Fertilization and Implantation
• Acrosomal reaction is
physiologically triggered
by the spermatozoon‘s
contact with the zona
pellucida (3):
• The outer acrosomal
and plasma membranes
fuse, with subsequent
release of hyaluronidase
and acrosin. Both have
lytic effects and
fascilitate the
penetration of the zona
pellucida.
• Fertilization (4):
- After penetration of the sperm, the egg cell
releases
granulae which inactivate subsequent spermatozoa and
make the zona pellucida impermeable (prevention of
multiple fertilization).
- Anatomically, fertilization occurs at the isthmo-ampullar
transition of the Fallopian tube.
- First divisions occur here.
- Early embryo is nourished by pyruvate and lactate from
the uterus.
- Embryo reaches uterine cavity 4-5 days post conception
in the morula-stage.
Fertilization and Implantation
• Timing of nidation:
- 5.9 - 7.5 days after conception
• The syncytiotrophoblast grows invasively
into the decidua and the endometrial
stroma followed by erosion of blood
vessel and invasion of the vessel system
(exchange of gases and nutrients).
Reproductive Health
Ability fertility
fertility regulation
sex
Success outcome of pregnancy

infant and child survival, growth and
development
Safety pregnancy and childbirth

fertility regulation
sex Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990
Estimates of world population
2000 6
Population
Years (billions)
1987 5
0 0.2
Population in billions
1830 1.0
1930 2.0 1975 4
1960 3.0
1975 4.0
1987 5.0 1960 3
2000 6.0
1930 2
about 1830 1
AD
0 1650 1700 1750 1800 1850 1900 1950 2000 2010
Years
Estimates and projections of the population size in the ten most
populous countries of the world in 1995 and 2025
Population (million) Percentag
Country 1995 2025
China 1222 1526 +25

India 936 1392 +49
United States 263 331 +26
Indonesia 198 276 +39
Brazil 162 230 +42
Russian Federation 147 139 -6
Pakistan 141 285 +102
Japan 125 122 -2
Bangladesh 120 196 +63
Nigeria 112 238 +113
UNFPA, 1995
Diczfalusy. The Contraceptive Revolution - An Era of Scientific & Social Development, 1997
Projected increase in the elderly population* between 1990 and 2025;
selected countries
Country Percentage increase

Indonesia 414
Thailand 337
India 242
China 220
Bangladesh 219
Australia 137
United Kingdom 45
Sweden
Population aged 65 years and over
33
WHO, 1995a Diczfalusy. The Contraceptive Revolution - An Era of Scientific & Social Development, 1997
Reproductive behavior
‘Too many, too close, too early, and
too late pregnancies are a major
cause of maternal, infant and
childhood mortality and
morbidity’
Mexico City Declaration on Population and
Development, August 1984

PERENCANAAN KELUARGA
1. Seorang wanita telah dapat melahirkan, segera
setelah ia mendapat haid yang pertama
(menarche)
2. Kesuburan seorang wanita akan terus berlangsung,
sampai mati haid (menopause)
3. Kehamilan dan kelahiran yang terbaik, artinya
risiko paling rendah untuk ibu dan anak, adalah
antara 20-35 tahun
4. Persalinan pertama dan kedua paling rendah
risikonya
5. Jarak antara dua kelahiran sebaiknya 2-4 tahun
Affandi, 1984
FAMILY PLAN
Phase Phase Phase

DIFFERING SPACING COMPLETING
2-4
20 35
Point of Intervention
HRH HRH
1. GnRH 2. GnRH
3. Steroid 4. Male Pill

5. Vaccin 6. Sperm Maturation
7. Tubectomy 8. Vasectomy
9. Tubal Transport 10. Capacitation

11. Vaccin
12. Coitus Interruptus,condom
14. Diaphraghm
13. Periodic Abstinence
15. Spermaticides
17. Emergency Contraception
16. IUD
18. Prostaglandin
19. Menstrual Regulation
20. Abortion T 1
21. Abortion T 2
22. Lactation
26
Affandi B. Research in Contraception : Emergency Contraception,.Kongres II PERMI,Surabaya,3-6Feb 2005
PEMILIHAN KONTRASEPSI RASIONAL
Fase Fase Fase

menunda Menjarangkan Tidak hamil
Kehamilan Kehamilan lagi
2-4
- Pil - IUD - Steril

- IUD
- IUD - Suntikan - IUD
- Suntikan
- Sederhana - Mini Pil - Implant
- Mini Pil 35
- Suntikan 20 - Suntikan
- Pil - Pil
- Implant - Implant - Sederhana
- Implant
- Sederhana - Sederhana - Pil
- Steril
Affandi, 1984
Affandi B. Upaya Peningkatan Kesehatan Ibu, Bayi dan Anak melalui penggunaan kontrasepsi , BKKBN Jawa Tengah , Semarang , 15
Current Contraceptive Users
Indonesia, March 2005
METHODS USERS %
INJECTABLES 9,743,550 35.2

PILLs 7,796,474 28.1
IUDs 5,218,196 18.8
IMPLANTABLES 3,156,705 11.4
STERILIZATION 1,515,406 5.5
OTHERS 278,473 1.0
TOTAL 27,708,804 100.0
BKKBN, 2006
PIL KB
Transdermal System
The Contraceptive Patch
Intra-uterine system:
Mirena®
• Metode jangka panjang

– 5 tahun yang reversibel
• Tingkat keampuhan
– pregnancy rate 0.5 dalam 5 tahun
32 mm
• Kadar LNG sistemic yang

rendah
• Menyebabkan perubahan
LNG dalam perdarahan haid
Reservoir • Biaya ~ US$ 450 IUS +
Pemasangan
Levonorgestrel
20 µg/day
The Contraceptive Vaginal Ring:
NuvaRing ®
Flexible, soft,
transparent ring
with outer
diameter of 54
mm and cross
section of 4 mm
NORPLANT® Capsule and JADELLE® Rod, Actual
Size
IUD-Cu
Affandi B. Research in Contraception : Emergency Contraception,Kongres II PERMI,Surabaya,3-6 Feb 2005
35
Primary infertility means that the couple
has never conceived, despite
cohabitation and exposure to pregnancy
for a period of 2 years.
Secondary infertility means that the couple has previously

conceived, but is subsequently unable to conceive despite
cohabitation and exposure to pregnancy for a period of 2
years.
Attribution of the cause of infertility
Developing countries (%)
Developed Latin Eastern
countries
Africa Asia Americ Mediterr
(%)
Male cause only 22 8 13 22 19

Female cause only 31 37 34 25 25
Cause found in both 21 35 24 30 38
No cause found
14 5 13 10 3
Became pregnant
12 15 16 13 15
Specific causes of male infertility
Developing countries (%)
Developed Latin Eastern
countries Africa Asia America Mediterran
(%) ean
No demonstrable 49 46 58 41 28
cause
21 13 19 25 33
Sperm defect
Accessory gland
7 11 3 12 3
Varicocele 11 20 10 19 12
Gap between mean age at marriage and mean
age at menarche
20
Age (years)
10
1900 1920 1940 1960 1980
Percentage of adolescents reported to have experienced
premarital sexual intercourse by a certain age, selected countries
Age Ever having intercourse (%)

Country (years) Males Females
Australia 20 58 47
West Germany 16 35 30
Israel 14-19 42 11
Japan 16-21 15 7
Nigeria 14-19 68 43
Rep. of Korea 12-21 17 4
Percentage of women who are married by ages
10-24, selected countries
Age group (years)
Country 10-14 15-19 20-24
Bangladesh 8.2 64.7 91.0

Indonesia 0.8 24.6 66.2
17.7
Mexico - 56.6
37.4
Pakistan 1.3 75.3
14.5
Peru - 49.0
3.2
Rep. of Korea - 6.2 43.6
Sri Lanka - 37.8
Annual worldwide incidence of the major
sexually transmitted diseases
Disease Millions
Trichomoniasis 120
Genital chlamydial infections 50
Genital human papillomavirus 30
infections
25
Gonorrhea
Genital herpes 20
Infectious syphilis 3.5
Chancroid 2.0
Total 250
In additional, over 1 million people a year are newly infected with HIV
WHO, 1993 Diczfalusy. The Contraceptive Revolution - An Era of Scientific & Social Development, 1997
Estimated burden of sexually transmitted
infections in society
Chancroid
Syphilis
Gonorrhoea
Chlamydia
Infection increaseingly
asymptomatic
Trichomonas
Increasingly risky
Genital herpes
Sex practices
Human
papilloma virus
Lancet, 2006
Global Problems
Problems N
Unmet Need Contraception 120 million
Unintended Pregnancies 80 million
Induced Abortions 50 million
Maternal Deaths >0.5 million
Child Deaths 5 million
Infant Deaths 10 million
Sexually Transmitted Infection 340 million
Infertile Couples
90 million
Lancet, 2006
Indonesian Problems
Problems N
Unmet Need Contraception 4 million
Unintended Pregnancies 4.5 million
Induced Abortions 3 million
Maternal Deaths 20,000
Child Deaths 100,000(?)
Infant Deaths 100,000(?)
Sexually Trans.Infection ?
Infertile Couples 4.5million
Improving reproductive health
• Socioeconomic conditions
• Status of women
• Sexual behavior
• Reproductive behavior
• Traditional practices
• Health care services
• Health professionals
Alasan untuk KB
New CONTRACEPTIVE CHOICES
1.PILLS
2.PATCHES
3.INJECTABLES
4.HORMONE-RELEASING IUDs
5.VAGINAL RINGS
6.IMPLANTABLES
Affandi B. Contraceptive Update . PIT XVII POGI , Balikpapan 28-30 July 2008
Pharmacokinetic Profile of Different Contraception
The Contraceptive Patch
Ortho Evra ®
What is Emergency Contraception?
• “A therapy for women who have had unprotected

sexual intercourse, including sexual assault.” –ACOG
• Not just the “morning-after pill” – hormonal EC can
be given between 72-120 hours after unprotected
intercourse
ACOG Practice Bulletin. Int J Gynecol Obstet. 2002;78:191-198.

LaValleur J. Obstet Gynecol Clin North Am. 2000;27(4): 817-839.
What is Emergency Contraception?
• “A therapy for women who have had unprotected

sexual intercourse, including sexual assault.” –ACOG
• Not just the “morning-after pill” – hormonal EC can
be given between 72-120 hours after unprotected
intercourse
ACOG Practice Bulletin. Int J Gynecol Obstet. 2002;78:191-198.

LaValleur J. Obstet Gynecol Clin North Am. 2000;27(4): 817-839.
Regimen Brand Name Doses Required Timing of Administration
I. Mechanical
Copper-IUD Copper T one insertion 5-7 days of unprotected sex
Multiload
Nova T
II. Pharmacological
- Oral-Combi- Microgynon 50 2 x 2 tablets first dose 72-120 hours of
ned Pill Ovral unprotected sex, second dose 12 hours later
(Yuzpe) Neogynon
Nordiol
Eugynon
Microgynon 30 2 x 4 tablets first dose 72-120 hours of
Mikrodiol unprotected sex, second dose 12 hours later
Nordette
Levonorgestrel Postinor 2 x 1 tablet of 0.75mg first dose 72-120 hours of
(or 1x1 tablet of 1.5 mg) unprotected sex, second dose 12 hours later
Oestrogen Lynoral 2,5 mg/dose first dose 72-120 hours of
Premarin 10 mg/dose unprotected sex, two doses per day
Progynova 10 mg/dose for 5 days
Mifepriston RU-486 1 x 600 mg 72-120 hours of unprotected sex
Danazol Danocrine 2 x 4 tablets first dose 72-120 hours of
unprotected sex, second dose 12 hours later
Affandi. J.Paed Obst & Gynec 1999, 25 : 33 - 37
Today’s World’s Challenges
 Income Poverty: More than one billion 35,000
US$ 34,134
people in the world live on less than

$1/day. Another 1.8 billion struggle to
30,000
GNI Per Capita

survive on less than $2/day. 25,00
0
 Hunger & Malnutrition: More than 20,000
800 million people go to bed hungry 15,000
every day; 300 million are children. 10,000
Every year six million children die from 5,000 US$ 670
malnutrition before their fifth birthday.
 Education: A total of 114 million 10 wealthiest 10 poorest
children don’t get even a basic countries countries
education and 584 million women are

illiterate.
 Health: Around 529,000 women are
dying / year in pregnancy & childbirth.
Every year 11 million children die from
preventable diseases. Every day
HIV/AIDS kills 6000 people and
another 8200 are infected with the
deadly virus
Global Response to These Challenges:
(also called the “silent tsunami”)
THE MILLENNIUM DECLARATION
• At the UN Millennium Summit in Sept 2000, 189
member states adopted the Millennium Declaration,
to cooperate on issues including development &
poverty reduction; peace, security & disarmament;
environmental protection; human rights, democracy
and good governance; etc.
• The Declaration is translated into the Millennium
Development Goals (MDGs) with specific, concrete
and inter-related targets, indicators and a time frame
to be achieved by 2015.
MELLINIUM DEVELOPMENT GOALS(MDGs)
Affandi B. Gambaran Kesehatan Ibu di Indonesia . Kuliah Department Ob.Gyn. FKUI/RSCM , Jakarta, Juli 2011
GOAL 5 Improve Maternal Health
TARGET 6
Reduce by three-quarters, between 1990 and
2015, the maternal mortality ratio

GOAL 4: Reduce child mortality
Family planning saves infant lives.
Spacing births and limiting
unintended births increases child
survival.
•Currently, 2.7 million infant deaths
are averted each year by the
prevention of unintended
pregnancies.
PROGRESS INDONESIA (4/8)
4. Menurunkan Angka Kematian Anak  menjadi 1/3-nya (2015)
Tantangan:
-Sebab kematian pada anak (ISPA, komplikasi perinatal, &
diare)
-Kesehatan neonatal & maternal
-Perlindungan & Pelayanan Kesehatan
-Penerapan desentralisasi kesehatan
MMR in Indonesia, Selected other
countries
Indonesia: 62% decline on 1990 levels, 5.4% annual change

66 Trends In Maternal Mortality 1990-2008, Source: WHO , 2010
MDG 5: Improve maternal health
– Target 5a: Reduce the maternal mortality ratio by ¾ (75%)
• Indicator 5.1 Maternal mortality ratio (MMR)
• Indicator 5.2 Proportion of births attended by skilled
health personnel
– Target 5b: Achieve universal access to reproductive health
by 2015
• Indicator 5.3 Contraceptive prevalence rate (CPR)
• Indicator 5.4 Adolescent birth rate
• Indicator 5.5 Antenatal care coverage
• Indicator 5.6 Unmet need for family planning
PROGRESS INDONESIA (5/8)
5. Meningkatkan Kesehatan Ibu  menurunkan angka kematian ¾-nya
Tantangan:
-Struktur penduduk  proporsi wanita subur tinggi meningkatkan kebutuhan lynn
kesehatan
-Penerapan desentralisasi kesehatan
-Keterbatasan biaya & tenaga
Persalinan 1 tahun terakhir oleh Nakes menurut Provinsi 2010
Sumber: Riskesdas 2010 69

Proporsi Persalinan menurut Tempat Melahirkan
70.0
60.0 55.4
50.0 43.2
Persen
40.0
30.0
20.0
10.0
1.4
0.0
Fasilitas kesehatan Polindes/Poskesdes Rumah/Lainnya
Tempat Melahirkan
• 51,9% persalinan ditolong bidan

• 40,2% ditolong dukun
Sumber : Riskesdas 2010

70
Kesenjangan Pelayanan Antenatal
K1 & K4
92.8
100
80 61.3
60
40
20
0
K1 K4
Sumber: Riskesdas 2010

71
• Maternal mortality is an
indicator of gross
inequality, human rights abuse
and development failure.
• “All maternal health problems
are preventable as long as the
government pays attention and
prioritizes maternal health.”
Dr. S.T.Mathai, UNFPA , The Jakarta Post , 13 Jan. , 2010
Affandi B. Kesehatan Reproduksi dan Upaya Kesehatan Maternal di Indonesia , Quo Vadis ? Orasi pada PIT XVIII-POGI , Jakarta , 7 Juli 2010
•Of the 11 countries that contribute to 65
percent to global maternal death, five are in
Asian countries including
Indonesia, Bangladesh, Pakistan , India and
Afghanistan.
•A high maternal mortality rate is an
indicator of the status of poor functioning of
a country’s health system including lack of
supportive and protective legal and policy
environment.
Dr. S.T.Mathai, UNFPA , The Jakarta Post , 13 Jan. , 2010
Affandi B. Kesehatan Reproduksi dan Upaya Kesehatan Maternal di Indonesia , Quo Vadis ? Orasi pada PIT XVIII-POGI , Jakarta , 7 Juli 2010
Affandi B. Upaya Peningkatan Kesehatan Ibu, Bayi dan Anak melalui penggunaan kontrasepsi , BKKBN Jawa Tenga
Thousands of Mrs.X still traveling
Three-pronged strategy
to reducing maternal mortality
■ Family planning to ensure that every birth is
wanted
■ Skilled care by a health professional with
midwifery skills for every pregnant woman
during pregnancy and childbirth
■ Emergency Obstetric Care (EmOC) to ensure
timely access to care for women experiencing
complications. UNFPA , 2009
CONTRACEPTIVE PREVALENCE
INDONESIA , 1970-2007
80
70 61.4 %
60 %
57 %
60
48 %
50
40
26 %
30
20
5 % (?)
10
0
1970 1980 1987 1997 2002 2007
Affandi B. Unsafe Abortion : Indonesian Experience . 1st International Congress on Women Health & Unsafe Abortion , Bangkok , Thailand , 20-23 January 2010
Senanayake P, Potts M. History of family planning. In: Senanayake P, Potts M, editors. Atlas of contraception. 2 ed. London, UK: Informa Healthcare UK, Ltd.; 2010. p. 24-5.
Affandi B. Perkembangan Kontrasepsi, Teknik Penapisan dan KB Postpartum , BPMPPKB, Balikpapan , 24 Juni 2010
WHAT IS SKILLED ATTENDANCE AT BIRTH?
• Skilled attendance refers to professionally trained
health workers with the skills necessary to manage
a normal delivery and diagnose or refer obstetric
complications.
• This usually refers to a doctor, midwife or nurse.
• Skilled attendants must be able to manage a normal
labour and delivery, recognize complications early
on and perform any essential interventions, start
treatment, and supervise the referral of mother and
baby to the next level of care if necessary.
• Trained and untrained traditional birth attendants
(TBAs) are not included in this category.
(WHO/UNFPA/UNICEF/WORLD BANK. JOINT STATEMENT FOR REDUCING MATERNAL MORTALITY, 1999. )
FAKTA
1.Pascasalin, OVULASI dapat
terjadi dalam waktu 21 hari
2.Pascakeguguran, OVULASI
dapat TERJADI dalam waktu
11hari
Contraceptive choices for breastfeeding women .Journal of Family Planning and Reproductive Health Care 2004; 30(3): 181–189
Affandi B. Kontrasepsi Terkini dan IUD Pascaplasenta . Pertemuan Koordinasi Peningkatan KB Pascapersalinan di Rumah Sakit , Makassar 31 Agustus 2010
Timing of IUD Insertion
• Interval insertions:
– any time woman is not pregnant and has
no signs of infection
• Postpartum insertions:
– immediately after vaginal or caesarean
delivery if no infection or hemorrhage
(within 48 hours or delay 4 weeks)
• Postabortion insertions (first trimester)
– immediately, if no infection
Tidak
menggunakan
kontrasepsi
40-50%
Diskusi kontrasepsi
pascasalin saat
kunjungan
antenatal 4% 8
Ingin menggunakan kontrasepsi
1 tahun pertama 50-96 %
Tidak ingin hamil dalam 2 tahun pascasalin

92-98 %
Teknik Pemasangan AKDR
Teknik Pemasangan AKDR
• Postplacental (preferably within
10 minutes after expulsion of the
placenta) and immediate
postpartum insertion during the
first week after delivery (but
preferably within 48 hours) are
convenient effective and safe
times to insert copper IUDs.
{Managing Contraception 2005-2007, page 92}
Fundal placement
• The way the IUD is inserted is more important than
the design of the device.
• Differences in IUD expulsion rates between centers
participating in the trials were generally greater than
expulsion rates for different IUDs;
• FHI data show that emphasis needs to be given to the
fundal placement of the device.
• The provider should be able to feel the device through
the abdominal and uterine walls at the time of
insertion.
• Retraining is necessary for those individuals who
report high expulsion rates www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm
Affandi B. Kontrasepsi terkini dan IUD pascaplasenta . Direktorat Kahiba , BKKBN . Banjarmasin 4 Nov.
2010
Simplified Classification of Eligibility
Criteria (WHO)
Progestin-only contraceptive
use during lactation
• Use of progestin-only methods, with the exception of the
levonorgestrel bearing IUD, is not usually recommended for
women who are less than 6 weeks postpartum and
breastfeeding, unless other more appropriate methods are
unavailable or unacceptable.
• Beyond 6 weeks postpartum, there is no restriction for the use of
progestin only contraceptive methods among breastfeeding
women.
• The levonorgestrel-bearing IUD is not usually recommended for
the first 4 postpartum weeks, unless other more appropriate
methods are unavailable or unacceptable. Beyond 4 weeks
postpartum, there is no restriction on its use.
Statement , WHO-Geneva , 22 Oct. 2008

Medical barriers
were defined as "practices,
derived at
least partly from a medical
rationale, that result in a
scientifically unjustifiable
impediment to, or denial
of, contraception" Shelton JD, et al. Lancet, 1992;340:1334-1335
Medical Barriers that restrict
access to family planning services
1. Provider bias — When the provider is
for or against a specific method
2. Overly restrictive eligibility criteria —
Who can get what contraceptive
3. Unnecessary process hurdles —
Requirements that, from the user's
point of view, make it difficult to
obtain a contraceptive Shelton JD, et al. Lancet, 1992;340:1334-1335
4.Inappropriate contraindications —
Medical conditions that restrict the
use of some contraceptives
5.Overly restrictive regulations —
National laws and clinic or hospital
regulations
6.Provider limitation — Who can
provide what method
7.Inappropriate management of side
effects — Actions taken by the
provider to help the user tolerate a
contraceptive method Shelton JD, et al. Lancet, 1992;340:1334-1335
Knowing is not
enough, we must apply
Willing is not enough, we
must do
…Goethe
Affandi B. Postpartum Contraception & Medical Barrier. Building Momentum MDGs 4&5, RSIA Budi Kemuliaan , Jakarta , 28 Sept. 2010

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REPRODUCTIVE HEALTH AND

MATERNAL HEALTH SERVICE

Klinik Raden Saleh

Success outcome of pregnancy

Safety pregnancy and childbirth

China 1222 1526 +25

Country Percentage increase

Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990

Phase Phase Phase

3. Steroid 4. Male Pill

9. Tubal Transport 10. Capacitation

19. Menstrual Regulation

Fase Fase Fase

- Pil - IUD - Steril

INJECTABLES 9,743,550 35.2

• Metode jangka panjang

• Kadar LNG sistemic yang

Secondary infertility means that the couple has previously

Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990

Male cause only 22 8 13 22 19

Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990

1900 1920 1940 1960 1980

Fathalla, Rosenfield, Indriso, et al., Reproductive Health Global Issues, 1990

Age Ever having intercourse (%)

Bangladesh 8.2 64.7 91.0

• “A therapy for women who have had unprotected

ACOG Practice Bulletin. Int J Gynecol Obstet. 2002;78:191-198.

• “A therapy for women who have had unprotected

ACOG Practice Bulletin. Int J Gynecol Obstet. 2002;78:191-198.

people in the world live on less than

GNI Per Capita

 Hunger & Malnutrition: More than 20,000

800 million people go to bed hungry 15,000

every day; 300 million are children. 10,000

education and 584 million women are

Reduce by three-quarters, between 1990 and

2015, the maternal mortality ratio

Indonesia: 62% decline on 1990 levels, 5.4% annual change

Sumber: Riskesdas 2010 69

• 51,9% persalinan ditolong bidan

Sumber : Riskesdas 2010

Sumber: Riskesdas 2010

Tidak ingin hamil dalam 2 tahun pascasalin

Statement , WHO-Geneva , 22 Oct. 2008

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