DRAFT: This module has unpublished changes.

Tackling the Problem of Diarrhea in Indonesia:

Breast feeding is the "Best" Feeding



Southeast Asia is a subset of countries, also known as the ASEAN (the Association of Southeast Asian Nations), and is comprised of Cambodia, Laos, Myanmar, Thailand, Vietnam, Malaysia, Brunei, Indonesia, the Philippines, and Singapore. The geographic area is a hot spot for seismic and active volcanoes. Along with the potential for natural disasters, Southeast Asia battles many public health issues, including a high rate of maternal and child mortality. This region accounts for one fourth of the world’s population, meaning its mortality rates add up to a heavy burden. According to the United Nations, 18,000 maternal and 400,000 total child deaths occurred in Southeast Asia in 2008, contributing to 33% of maternal mortality worldwide. Of the ten ASEAN countries, only Brunei, Singapore, and Malaysia have infant and under-five mortality rates below 10 per 1000 live births. [1] [2] Though progress has been made toward the UN Millennium Development Goal 4 (MDG4), reduction in child mortality has been uneven throughout Southeast Asia; several countries’ rates have declined since 1990, but have leveled off in recent years. Because nearly 50% of the region’s population is under 15, approaching reproductive age, initiatives to improve maternal and child health are of crucial importance.[3]


The breakdown of maternal and child deaths can be seen in the graphs below. Figure 1 shows hemorrhage as the leading cause of maternal mortality in Southeast Asia, with many deaths due to delays in emergency obstetric care. Hypertensive disorders and unsafe abortion are other leading causes of maternal deaths.[1]  Many of these deaths could be prevented through proper maternal care during pregnancy and childbirth. As seen in Figure 2, most mortality for children under five is attributed to preterm complications. This can be attributed to a lack of appropriate prenatal care including identification and treatment of infectious diseases, poor maternal nutrition, and a lack of skilled birth attendants to handle complications. Though a majority of deaths are due to various neonatal problems, infectious diseases such as pneumonia and diarrhea account for almost half of child deaths in Southeast Asia.[1]


(Data in the above charts, Figures 1 & 2, taken from The Lancet [1])[1]


Rates of mortality from diarrhea have been reduced worldwide through many various initiatives, making the disease seemingly preventable. For instance, in Indonesia, the most populated country of Southeast Asia, diarrhea had once been a major cause of death for children-under-five, causing around 25% of child deaths. Recent estimates from the country cite death rates from diarrhea at 2.5/1000 in children-under-five, yielding an encouraging decrease in mortality. However, the incidence of diarrhea has remained constant despite multiple interventions in place to combat mortality. Though difficult to quantify, Indonesia reports 25-30 million cases/year of diarrhea in children-under-five.[4] The stagnant rates of morbidity suggest a need for the creation of more innovative solutions to combat diarrhea in the country.[2]


Current Interventions


Interventions have been largely influenced by the United Nations’ Millennium Development Goals - a coordinated effort amongst various global organizations and the world’s leading countries to eradicate poverty, improve health, and achieve equality through education and economic relief. Among the goals, maternal and child health are two major categories; specifically the goals are to: 1. Reduce under-five mortality and 2. Reduce maternal mortality as well as bring universal access to reproductive health.[5]  Some of the best practices that have played a large role in reducing maternal mortality include the provision of modern contraceptives and training professionals to aid the birthing process and/or follow-up of childbirth. Likewise, promoting exclusive breastfeeding and providing vaccines were substantial efforts that helped in reducing child mortality rates.[3]


Best Practices


The World Health Organization, UNICEF, UNFPA, UNAIDS, and USAID are a few of the larger organizations that are at the forefront of improving and documenting maternal and child health in the Southeast Asian region. Changes in policy, particularly in universalizing health care coverage, and other government initiatives have played an important role in improving the health of mothers and children in countries such as Thailand.[6] Effective interventions have included cooperation and coordination between different agencies, departments, ministries, public and private sectors, and NGOs.[1] Epidemiologists and statisticians have also played a vital role in improving maternal and child health. These scientists work alongside agencies to find solutions to the health problems faced by the population. Interventions backed by scientific evidence have produced significant results, such as in the case of Oral Rehydration Therapy (ORT).[3]  In Indonesia, USAID sponsored a campaign to teach healthcare workers and mothers to make and use a simple solution composed of salt, sugar, and water, to reduce infant mortality due to diarrhea.[7] Finally, the work of medical anthropologists and sociologists has also attributed to successful interventions, such as in investigations of the practice of midwifery in various regions.[8][9]


 Some of the best practices are seen in Thailand and Sri Lanka - countries that have been deemed “success stories”. These include using Maternal and Child Health Handbooks, increasing antenatal care, implementing the Healthy Daycare Program, creating local and provincial Maternal and Child Health committees, immunizing pregnant mothers with Tetanus Toxoid, immunizing children against Rubella, and improving facility sterilization.[10][11] Borrowing ideas and techniques from these successes would likely help the organizations that are continually making an effort to improve health in Southeast Asia.




Indonesia Context


Among the Southeast Asian countries, Indonesia is the largest country, with a population of 245 million people – three times larger than the next most populous country in the region, which has a population of 88 million.[12]  Indonesia consists of over 17,000 islands, of which Java reports the highest population, around 135 million people. This makes Java not only the most populated island in Indonesia, but also in the world; moreover, its relatively small size means Java is the most densely populated island as well.[13] As mentioned previously, Southeast Asia is prone to natural disasters such as floods, severe droughts, tsunamis, earthquakes, and forest fires. Indonesia is particularly vulnerable to natural disasters since it houses the highest number of volcanoes in the world (over 150, 76 of which are active).[14]  While Indonesia’s location makes it highly susceptible to natural disasters, it also allows for a wealth of natural resources including gas, oil, minerals, and agriculture. Along with the access to natural resources, Indonesia’s sizeable population provides a large source of labor to make use of these resources.[13] With proper resource and labor management and distribution, Indonesia has great potential to increase its economic growth and support its population.


Over the years, Indonesia has been hit repeatedly with natural disasters, such as the 2010 Merapi eruption and the 2005 tsunami, allowing little time for recuperation, especially for those in the lower socioeconomic status. Around 77 million people, most from rural and low-income urban populations, lack access to safe and affordable drinking water, making them susceptible to water-born diseases.[15] Bacterial diarrhea alone causes 100,000 deaths per year in Indonesia and was one of the highest ranked reasons for hospitalization in 2003.[15][16]


More than 12% of Indonesians live below the poverty line and tens of millions more live just above it.[17] It is important to keep in mind that although 12% sounds relatively small, this percentage translates to 40-50 million people. Knowing that low socioeconomic status is often the leading determinant of population health, changes and improvements to the country’s status are important.[18] Indonesia has a consistent annual growth rate of 1.4%, contributing to its high youth population (described as those under 18 years old) which composes almost 50% of the total population.[12] This high growth rate could help explain why Indonesia holds one of the highest maternal and under-5 child mortality rates in Southeast Asia, 240 deaths per 100,000 live births and 27 deaths per 1000 children respectively.[19] In order to reach the Millennium Development Goals, these issues must be addressed.


Interventions in Indonesia


In the case of maternal and child health, programs in Indonesia have been focusing the majority of their attention on improving the safety of pregnancy and the nutrition of children. Some examples of best practices of this are the Safer Pregnancy program started by USAID and the Positive Deviance Program implemented by The Foundation for Mother and Child Health, devoted to decreasing the mortality rate and complications caused by pregnancy and improving the nutrition of children, respectively.[20][21] The mortality rates of women and children in Indonesia have been decreasing: from 620 maternal deaths to 240 per 100,000 live births and from 85 deaths to 27 per 1000 children under 5 in 1990 to 2009, suggesting that there has been an improvement in health care systems in the country.[19] Notwithstanding, the rates are still higher than desirable, and look alarmingly high when compared to the rates of other Southeast Asian countries, as seen in Figures 3 and 4 below. While strides are being made to improve healthcare systems, a larger effort to address all of the contributing factors leading to the poor health of women and children in Indonesia needs to be seen. In order to achieve this, there should be a focus on starting better sanitation programs and teaching mothers and health care workers the importance of preventative measures and simple treatments for illnesses.



  (Data in the above tables, Figures 3 & 4, taken from The World Bank [22])


Best Practices


USAID has shown much interest in helping Indonesia to improve health and to train mothers in giving care. Through their work like the Safer Pregnancy program and the Clean Water for an Indonesian Village program, USAID has made progress toward providing a good foundation to help the population of Indonesia work toward a healthier life.[20] By providing guaranteed transport to the hospital for expectant mothers and teaching them about pregnancy and childcare, the Safer Pregnancy program has allowed these women to focus on caring for themselves and their new babies rather than worrying about the birthing process and their safety during it. Through the Clean Water program, USAID helped a village to build pipes to bring clean water to the homes of the villagers while teaching them the importance of their environment and how to conserve the resources it provides. Instead of only providing clean water to improve health, the USAID workers also gave the villagers tools and knowledge they could use on their own once the program was complete.


Another way Indonesia has attempted to reduce the number of maternal and child deaths is through the use of the Integrated Management of Childhood Illness (IMCI). This was adopted in 1997 to promote health and prevent disease by using community health posts staffed by health volunteers under the supervision of a visiting nurse or midwife. The posts provide services to families such as growth monitoring, nutrition guidance, health education, and immunizations, and the midwives ensure a safe delivery and postnatal care for mothers.[22]


BEHAVE Framework

The literature on maternal and child mortality in Indonesia addresses several health problems as well as promising interventions occurring in the country. The morbidity of diarrhea in children-under-five is an especially prominent issue in the country, with little improvement being made in this area. As evidenced though the literature, breastfeeding behavior plays an integral role in this issue as studies have shown that infants who are not breast-fed have a 25-times greater risk of dying from diarrhea compared to those who are exclusively breastfed.[23]

A helpful tool used in designing effective behavior change programs is the BEHAVIOR framework. Using this framework, a link is defined between childhood diarrhea and the problem behavior of early weaning practices or mixed feeding (use of formula, rice-milk or other feeding in addition to breast milk). The target group of the problem behavior includes mothers in North Jakarta who are not exclusively breastfeeding their child for the first six months, since this is the duration of the breastfeeding law. Groups supporting this behavior are family members (immediate and extended family), employers, village elders, traditional healers, religious leaders, community health workers, and midwives.

It is essential that with every program intended to help improve health, there should be a focus on involving the community. Since permanent change often involves changes in behavior that is ingrained as the norm, it is crucial to research and investigate the determinants specific to the culture and area to ensure success. 

DRAFT: This module has unpublished changes.