Family Planning Service Program (KB)

Applying Evidence-based Advocacy in a Decentralized Context
In 2001, Indonesia’s administrative and financial powers of government were rapidly devolved to 550 districts, in what is now described as the “Big Bang Decentralization”. This mass decentralization included budgeting for health services and supplies. In the intervening years, district governments have struggled to identify which health issues to prioritize and the level of funds needed to achieve improved health outcomes.

In addition, the National Family Planning Board’s (BKKBN’s) role in championing the value of family planning as a health intervention diminished at the local level. Without adequate evidence and expertise, commitment and resources to promote and provide access to family planning dwindled.

So, The project (KB) must rekindle local commitment to family planning and reengage champions, expanded to all of the district, aims to increase access to quality family planning services among low- and middle-income populations, including marginalized groups and communities living in remote villages.


Fewer Women Die When Pregnancies are Planned
Family planning (KB)  saves women’s lives in two ways. First, family planning helps women avoid  unwanted pregnancies. Each year, 687,000 maternal deaths are averted with family planning  versus the 533,000 maternal deaths that occur (red: Personal communication with Amy Tsui, Professor, Johns Hopkins School of Public Health and Director, Bill and Melinda Gates Institute for Population and Reproductive Health. Calculations based on Liu L, et al. Three methods of estimating births averted nationally by contraception. Population Studies, 2008 July; 62(2): 191-210).

As shown in the graph (Calculations for maternal mortality rate by Carie Muntifering, Doctoral Candidate, Johns Hopkins School of Public Health. Calculations based on: World Health Organization. Trends in Maternal Mortality:1990 to 2008. Estimates Developed by WHO, UNICEF, UNFPA and the World Bank, Geneva: WHO, 2007 and World Population Prospects: The 2008 Revision Population Database. United Nations, 2008. http://esa.un.org/UNPP/, accessed 13 Dec 2010.) the more couples practice family planning, the fewer women die from pregnancy-related causes (World Health Organization. Trends in Maternal Mortality:1990 to 2008. Estimates Developed by WHO, UNICEF, UNFPA and the World Bank, Geneva: WHO, 2007) Women who are not pregnant do not die from pregnancy-related causes.



Second, family planning helps couples plan the size of their family and avoid high-risk pregnancies. Women who become pregnant when very young or very old are at a higher risk of a pregnancy-related death. Women who become pregnant soon after their last birth or who have many children also have an increased danger of maternal death. Fewer deaths will occur among pregnant women if more couples practice family planning.


Why is maternal mortality an important issue to tackle?

1. The death of a mother can devastate and destroy families.
2. The majority of maternal deaths are preventable.  We have the knowledge and tools to prevent maternal deaths including modern contraception and emergency obstetric care.
3. Decreasing maternal mortality has become an international priority and is a key indicator of the Millennium Development Goals.

The main direct causes of maternal deaths are hemorrhage (severe bleeding), hypertensive disorder, sepsis/infection, obstructed labor, and abortion. Common indirect causes include HIV/AIDS, malaria, tuberculosis, and anemia. In Asia, hemorrhage is the number one cause of maternal mortality. For every woman who dies a maternal death, 20 more experience serious complications.

Maternal mortality rate is the number of maternal deaths in a given period per 100,000 women of reproductive age during the same time-period.

Increasing family planning use can help reduce the maternal mortality rate by decreasing the number of women with an unintended pregnancy, which decreases the number of women of reproductive age at risk for maternal death.

Maternal mortality ratio is the number of maternal deaths during a given time period per 100,000 live births during the same time-period.

Increasing family planning use can also reduce the maternal mortality ratio by helping women avoid high-risk pregnancies.

Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. -World Health Organization

A woman who is not using a modern or traditional method of contraception but reports wanting to either delay childbearing for at least two years or stop childbearing altogether is classified as having an unmet need for family planning.  Without contraception, millions of women with an unmet need for family planning will become unintentionally pregnant each year which in turn increases the number of women who are at risk for maternal mortality. Satisfying the unmet need for family planning would decrease maternal mortality in Indonesia.

It is estimated that 240 women die out of 100,000 live births each year in Indonesia, resulting in a total of 10,000 maternal deaths every year. Improving access to family planning and maternal health services in Indonesia would help to decrease the number of maternal deaths. 

Over half of all married women in Indonesia report not wanting another child. Long term, highly effective methods of contraception such as the IUD, implants, or sterilization are ideal for women who want to stop childbearing completely, however, only 11% of married women in Indonesia report using a long term method of contraception.4 Helping women to avoid unintended pregnancies through use of effective contraceptive methods will reduce maternal mortality in Indonesia.  


Too Young, Too Old, Too Close, Too Many

1. When a woman becomes pregnant before age 18 she is more likely than an older woman to develop hypertension, anemia and prolonged or obstructed labor (World Health Organization. Report of a WHO Technical Consultation on Birth Spacing, 13–15 June 2005: Geneva, Switzerland. Geneva: Department of Making Pregnancy Safer, Department of Reproductive Health and Research, World Health Organization, 2006) and to die as a result of pregnancy (DaVanzo J. et al. Pregnancy Outcomes, and Maternal Morbidity and Mortality in Matlab, Bangladesh. RAND, Labor and Population working paper series, 2004)
2. For pregnancies among women in their 40s, the risk of death can be as much as seven times higher than among women in their 20s.
3. When pregnancy occurs less than six months from the last birth, a woman is more than twice as likely to die in childbirth than a woman who becomes pregnant between 18 to 23 months later.(Conde-Agudelo A and Belizan JM. Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study. British Medical Journal, Nov 2000; 321: 1255-1259)
4. Five or more pregnancies significantly increase the risk of dying of pregnancy-related causes (Chen LC, et al. Maternal mortality in rural Bangladesh. Studies in Family Planning, 1974, 5(11), 334-341.)

Saving the Lives of Indonesia’s Women
It is estimated that for every 100,000 babies born, 240 women die in Indonesia (World Health Organization. Trends in Maternal Mortality:1990 to 2008. Estimates Developed by WHO, UNICEF, UNFPA and the World Bank, Geneva: WHO, 2007.). This estimate indicates that progress is being made but there is more work to be done. Contraceptive use is fairly high in Indonesia with 57% of married women currently using a modern method.

However, only 11% of married women report using a highly effective, long-term method of contraception despite over 50% of married women reporting not wanting anymore children (Macro International Inc. MEASURE DHS STAT compiler. http://www.measuredhs.com, accessed 07 Dec 2010).

Increasing women’s access to and knowledge of longterm methods would result in fewer unintended pregnancies and fewer maternal deaths each year.

Project Case
The rate of Bandung Regency population growth is 2.56 percent. Based on the number of population in 2010, 3,111,602 people, we can make projection number of population in the following year which assuming no significant change in the Family planning and population program. The diagram shows the projection results:

These appears that every year, 55,673 babies will be born in Bandung Regency:
2011     3.191.259
2012     3.272.955       
2013     3.356.743   
2014     3.442.675   
2015     3.530.808


Consequences of Growth at This Level
Population growth at this level (2.56 percent) brought many consequences, including:

1. From the aspect of child health financing based on the standards used by the Ministry of Health, health care costs per child up to the age of 5 years is Rp. 581,855.83. This means that the local government must pay the health of children over five years in the future for Rp. 161,968,298,118.00 (the result of the calculation: 55,673 children x 5 years x Rp. 581,855.83).
2. From the aspect of educational provision and financing of local government need to provide facilities and other costs when the babies who have born into the school-age.
3. From the aspect of job creation. The same also applies when the children already finish their school, then the number of jobs that must be provided in accordance with the population growth rate. Children who drop out of school will enter the labor market earlier. The consequence is that they will enter the labor force without the skills and competence.

Investing in Family Planning and Population Sector
Efforts to reduce the rate of population growth can be done with the revitalization of family planning programs. If the rate of population growth can be reduced through the decreased in birth rates into 36,680 infants each year, the investment in this KB will save Rp. 55,255,938,896 for five years. This figure only includes child health savings, not taking into account savings in other sectors. Funds obtained from these savings can be used to finance other development or improve the quality of health care and education to the infants which born. The other hand, this will have an impact on improving the quality of human resources and improvement of the Human Development Index (HDI) of Bandung regency.


What Can Be Done?
Local Government can increase investment through the budget increase in the field of family planning, a positive impact will happen on other areas (health, education, quality of human resources, etc.). So Bandung Regency can organize more effectively the KB with the implementation of a Long Term Contraception Method (LTM), such as the IUD, implants, Vasectomy (MOP, Operation Method Man) and Tubectomy (MOW, Women Operating Method).

Mayors Indonesian in city/regency increased their budgets for family planning substantially, prompted by evidence on the returns for their investment. The budget increases ranged from 20% in Bandung, for example, to nearly 80% from 2010 to 2013.

Advocates in several  city/regency to initiative to gather and synthesize the evidence for increasing allocations and presented it to the mayors. Budget allocations for family planning are a critical first  step towards increasing access to contraceptives; in the context of decentralized authority,  allocations more easily translate into actual disbursements and services. Local govermnet  are using the funds to:

1. Procure contraceptive stocks of long acting and permanent contraceptive methods (LAPMs), including implants and intrauterine devices (IUDs);
2. Support field worker services for community mobilization and demand creation; and;
3. Provide equipment for hospitals, clinics, and mobile outreach services.

So, What Can Be Done, Again
1. Make family planning services and supplies available for highly effective, long-term contraceptive methods in the Indonesian health system.
2. Ensure that Indonesian women and couples are able to plan their families and avoid unwanted and high risk pregnancies.

Source:

1. Analysis of Reproductive Health Financing Working Group conducted by the Regency of Bandung with UNFPA RH Costing Tools 2010.
2. Census Demographic Health Indonesia, Central Bureau of Statistics, 2007.
3. Population Census 2010, Central Bureau of Statistics.
4. Minimum Service Standards (MSS) of the Ministry of Health