Obesity as a poverty-related emerging nutrition problems: the case of Indonesia.

Obesity is a major contributor to the global burden of chronic disease and disability. In developing countries like Indonesia, obesity often co-exists with undernutrition. Data from national basic health research 2007 showed that overnutrition was found among all age groups, on a double digit scale, with similar magnitude in urban and rural areas and higher prevalence in adult female. In contrary to 14% undernourished children under the age of 5 years, 12% of their counterparts were overnourished; for 6-14 years 10% vs. 6%; and for 15 years and above 15% vs. 19%. The purpose of the review is to raise awareness on the increasing obesity problem and to set recommendations to prevent obesity. Stunted adults in developing countries are 1.2 times more likely to be overweight than non-stunted adults. Approaches to overcoming obesity in adulthood emphasize dietary changes, increasing physical activity and behaviour modification. It is important for Indonesia to target nutrition intervention for female adolescents, pregnant woman to first 2 years of life, initiate nutrition education for school-age children and disseminate Holistic Healthy Framework Approach with key message 'Initiate healthier food choices'. Prompt Nutrition Guidelines and the use of lower body mass index cut-off should be considered.

Professional assistance during birth and maternal mortality in two Indonesian districts.

OBJECTIVE: To examine determinants of maternal mortality and assess the effect of programmes aimed at increasing the number of births attended by health professionals in two districts in West Java, Indonesia. METHODS: We used informant networks to characterize all maternal deaths, and a capture-recapture method to estimate the total number of maternal deaths. Through a survey of recent births we counted all midwives practising in the two study districts. We used case-control analysis to examine determinants of maternal mortality, and cohort analysis to estimate overall maternal mortality ratios. FINDINGS: The overall maternal mortality ratio was 435 per 100,000 live births (95% confidence interval, CI: 376-498). Only 33% of women gave birth with assistance from a health professional, and among them, mortality was extremely high for those in the lowest wealth quartile range (2303 per 100,000) and remained very high for those in the lower middle and upper middle quartile ranges (1218 and 778 per 100,000, respectively). This is perhaps because the women, especially poor ones, may have sought help only once a serious complication had arisen. CONCLUSION: Achieving equitable coverage of all births by health professionals is still a distant goal in Indonesia, but even among women who receive professional care, maternal mortality ratios remain surprisingly high. This may reflect the limitations of home-based care. Phased introduction of fee exemption and transport incentives to enable all women to access skilled delivery care in health centres and emergency care in hospitals may be a feasible, sustainable way to reduce Indonesia's maternal mortality ratio.

Two models of in-service training to improve midwifery skills: how well do they work?

This program evaluation compared the knowledge, confidence, and skills of Indonesian village midwives who attended an intensive in-service training with midwives who received an internship program and midwives who attended no program. The five key skills compared were prevention of infection, use of the partograph, manual removal of placenta, bimanual uterine compression, and neonatal resuscitation. Midwives from the intensive in-service that combined competency-based skill training with peer review and continuing education scored higher on the knowledge test and demonstration of the five key skills and reported managing complications better than midwives who attended no training program. Midwives from the internship program scored intermediate between the intensively trained and the untrained midwives. Overall, skill scores were 71% for midwives in the intensive program, 62% for the interns, and 51% for midwives with no in-service training. Village midwives from the intensive program scored significantly higher in the practical demonstration of manual removal of placenta, bimanual compression, and neonatal resuscitation than the interns, but the scores on infection prevention and use of the partograph were not different between the two groups. Differences in the volume of training opportunities between the two programs could be responsible for the different outcomes.

Reaching young Indonesian women through marriage registries: an innovative approach for anemia control.

In an effort to build iron stores before pregnancy and reduce the high prevalence of anemia in Indonesia, the Ministry of Health/Indonesia and the MotherCare project implemented an anemia control program for newly wed women. As part of an existing program to counsel couples about marriage and require them to obtain tetanus toxoid immunization before obtaining a marriage certificate, women also were counseled to buy and take 30-60 iron-folate (IFA) tablets. Women (n = 344) were enrolled from one of three participating districts in South Kalimantan, Indonesia. At first monitoring, at least 30 d after baseline, 261 women were tested for hemoglobin and asked about their IFA tablet consumption and knowledge of information, education, and communications (IEC) materials promoted through the program. Results showed that there was a decrease in the prevalence of anemia from 23.8 to 14.0% over the course of the program, 98% of women had taken at least some IFA tablets and 56% had taken >30 tablets.

Use of hospital data for Safe Motherhood programmes in south Kalimantan, Indonesia.

The evaluation of Safe Motherhood programmes has been hampered by difficulties in measuring the preferred outcomes of maternal mortality and morbidity. The need for adequate indicators has led researchers and programme managers alike to resort to indicators of utilization and quality of health services. In this study we assess the magnitude of four indicators of use of essential obstetric care (EOC) and one indicator of quality of care in health facilities in three districts in South Kalimantan, Indonesia. The general picture which emerges for South Kalimantan is that the use of obstetric services is low. Even in the more urban district of Banjar where facility-based coverage is highest, fewer than 14% of all deliveries take place in an EOC facility, 2% of expected births are admitted to such a facility with a major obstetric intervention (MOI), and 1% of expected births have an MOI for an absolute maternal indication. The use of facility-based EOC is consistently lower in Barito Kuala compared to the other districts, and the differences persist regardless of the indicators used. In this setting with low utilization rates, general rates of utilization of EOC facilities seem to be as satisfactory an indicator of relative access to EOC as more elaborate indicators specifying the reasons for admission. The inequalities in access to care revealed by the various indicators of use of EOC services may prove to be a more powerful stimulus for change than the widely reported and highly inaccurate accounts of the high levels of maternal mortality.

Women's recall of obstetric complications in south Kalimantan, Indonesia.

The search for indicators for monitoring progress toward safe motherhood has prompted research into population-based measures of obstetric morbidity. One possible such measure is based on women's reports of their past childbirth experiences. In this prospective study in three hospitals in South Kalimantan, Indonesia, the accuracy of women's reporting of severe birth-related complications was examined. The findings of this study suggest that poor agreement exists between the way women report their experience of childbirth and the way doctors diagnose obstetric problems, although the degree of agreement varies with the type of complication. Questionnaires relying on women's experience of childbirth will tend to overestimate the prevalence of medically diagnosed obstetric problems such as those associated with excessive vaginal bleeding or dysfunctional labor. Questions suggestive of eclampsia may be more promising, although the small number of eclamptic women in this study precludes firm conclusions.

Effective community intervention to improve hemoglobin status in preschoolers receiving once-weekly iron supplementation.

The effect of weekly iron supplementation with and without deworming on hemoglobin was investigated in a double-masked, placebo-controlled field trial. Subjects were 289 preschoolers who were randomly divided into three groups. Groups 1 and 2 received 30 mg Fe once weekly and group 3 received a placebo. Group 1 additionally received anthelminthic treatment. Supplements were administered by the mothers, who were educated about iron deficiency beforehand. In the iron-supplemented groups prevalence of anemia decreased from 37.2% to 16.2% (P < 0.001). Hemoglobin increased by an average of 6.9 +/- 9.8 g/L in the two iron-supplemented groups (n = 191), which was greater (P < 0.001) than the increase of 1.9 +/- 8.0 g/L in the placebo group. None of the subjects had hookworm, and anthelminthic treatment did not have an additional effect. Iron supplements administered once weekly by mothers reduced anemia without major involvement of health staff.

PIP: The authors investigated the effect of weekly iron supplementation with and without deworming upon hemoglobin in a double-blind, placebo-controlled field trial conducted in the West Javanese village of Setia Asih. 289 children aged 2-5 years were randomly divided into three equal-sized treatment groups for the study. Groups one and two received 30 mg iron once weekly, while group three received a placebo. Group one also received anthelminthic treatment. Supplements were administered by the mothers who were taught about iron deficiency beforehand. In the iron-supplemented groups, the prevalence of anemia decreased from 37.2% to 16.2% and hemoglobin increased by an average of 6.9 +or- 9.8 g/l. However, hemoglobin increased only 1.9 +or- 8.0 g/l in the placebo group. No subjects had hookworms, so anthelminthic treatment had no additional effect.

Women's nutritional status, iron consumption and weight gain during pregnancy in relation to neonatal weight and length in West Java, Indonesia.

Pregnant and non-pregnant women in Indramayu, West Java were examined for nutritional status, using anthropometric indicators. For the pregnant women, longitudinal data on nutritional status, iron consumption and weight gain were examined in relation to neonatal weight and length. Comparing the non-pregnant women's average nutritional status with reference tables for height, weight and MUAC, they placed at the 25th percentile or less on all indicators. Using original formulae to estimate pre-pregnancy weight and pregnancy weight gain, the study showed that 18% of pregnant women had a pre-pregnancy weight of under 40 kg and the average pregnancy weight gain was under 9 kg. Comparing estimated pregnancy weight gain with the amount of weight gain needed to compensate for generally low pre-pregnancy weight, only about 9% of women gained adequately. In multiple regression models that controlled for other maternal and neonatal factors, iron consumption during pregnancy was a significant predictor of full-term (37 weeks or more) neonatal weight (P = 0.01) and length (P = 0.01). Consumption of one or more tablets (200 mg ferrous sulfate and 0.25 mg folic acid) per week by women during pregnancy was associated with increased neonatal weight (by 172 g on average) and length (by 1 cm on average). Adequate weight gain during pregnancy and maternal height also contributed to the specification of the neonatal weight model (P = 0.07 for both). In the neonatal length model, maternal height was also nearly significant (P = 0.03). The same models did not explain the variability in neonatal weight and length in the pre-term group (< 37 weeks gestation).