Amino PCC EAMSC 2018

ABSTRACT

LACK OF KNOWLEDGE AS A RISK FACTOR OF HIGH-RISK PREGNANCY Azarine Neira Avisha, Belinda Anasthasya Tansy, Nuruddin Dzulkarnain, Ika Puji Dana Savitri Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia

Aim To determine the contribution of knowledge to the pregnancy risks of “ the four extreme” (too old, too young, too many and too close) in Surabaya, Indonesia.

Background Maternal and neonatal health are important factors that need to be considered in SDGs, because maternal and neonatal health are indicators of a country's health level. One of the indirect causal factors that cause high maternal mortality is the existence of unfavorable pregnancy factors called “the four extreme”, including too young, too old, too many, and too close.

Material and Methods This descriptive study was carried out using a cross sectional design on 100 women who had children and lived in Surabaya, East Java, Indonesia. The demographic, knowledge and the pregnancy risks data were obtained using a questionnaire. All study participants agreed to sign the informed consent voluntarily. The research ethics approval was acquired from the Human Research Ethics Committee at Hang Tuah University (No. 8/M/KEPUHT/X/2017).

Results Majority of study participants were housevives and their mean age was 41 years old. Of the study participants, 68% did not know about "the four extreme" as high-risk pregnancy, while 32% knew about it. The prevalence of women who had experienced a high-risk pregnancy among those who did not know and among those who knew about “the four extreme” was 17% and 6%, respectively.

Conclusion Women who did not know about “the four extreme” had 2.83 times higher risk of developing a high-risk pregnancy, compared to women who knew about “the four extreme”.

In Indonesia, many programs have been implemented to reduce maternal mortality, but they had to be re-evaluated. High-risk pregnancy could be prevented to achieve maternal and neonatal health.

We suggested some solutions, including high-risk pregnancy awareness campaign, the promotion of

family planning program, and the prevention of young marriage. All the efforts should be carried out with cross-sector collaboration.

Nifedipine, Calcium Channel Blocker, as Tocolytic for Inhibiting Preterm Delivery: A Systematic Literature Review of Randomized Controlled Trials Joue Abraham Trixie1, Abigail Serepina Siagian2, Mathilda Abigail Irianti3 1. Universitas Kristen Indonesia – (+62) 81574924922, joueabraham@gmail.com 2. Universitas Kristen Indonesia – (+62) 81314752976, serepinabigail@gmail.com 3. Universitas Kristen Indonesia –(+62) 81240314576, abigaelmarpaung@gmail.com

Aim: 1) Find new ways to prevent preterm birth 2) Discuss whether calcium channel blockers can prevent preterm birth better than the existing tocolytics 3)Assess the efficacy and safety of calcium channel blockers, both in pregnant women and infants.

Introduction: Globally, the premature births are number 1 cause of death in children under 5 years.

Fifteen million babies are born prematurely as estimates. Nearly 1 million children die every year because of the premature as the complication. Many also survive, but live with disabilities. Disability such as respiratory disorders, eating disorders, cerebral palsy, growth disordes, visual disorders, and hearing loss. By 2015, 1 in 10 children in America, was born prematurely. Indonesia is ranked 5th out of 10 countries with the highest rates of preterm birth. The government needs to improve antenatal care services to address this issue. The therapy that used to deal with early uterine contractions is by giving tocolytics. Tocolytic can endure pregnancy, so there is enough time for the lung maturation for the fetus.

One of them is nifedipine, calcium channel blocker.

Methods: Comprehensive literature searches was conducted in October 2017 using the database such as PubMed Central, PubMed Health, The Cochrane Library, ScienceDirect, MedlinePlus, The Lancet, The Journal of Maternal-Fetal & Neonatal Medicine, and Sage Journal. Randomized controlled trials on pregnancy women with early contractions who consume nifedipine were selected. Trials were further filtered using inclusion and exclusion criteria. Data extracted from selected trials were include prolongation of delivery, maternal outcome, and neonatal outcome.

Results: The systematic review includes 5 randomised controlled trials with a total of 612 participating women. Calcium channel blockers appear to be more effective than other tocolytic agents in prolonging pregnancy for 7 days or longer, are much less likely to cause maternal side-effects and are associated with reduced neonatal morbidity. Out of the 626 babies who were born, 31 of them were dying. The causes

include

Respiratory

Distress

Syndrome,

septicemia,

intraventricular

hemorrhage,

bronchopulmonary dysplasia, sepsis, and necrotizing enterocolitis. In some infants may also experience meningitis, pneumothorax, apnoe, and asphyxia. But, in small quantities.

Conclusion: Calcium channel blockers, nifedipine can be considered safer and more effective tocolytic agents than other tocolytic

Key words: Calcium channel blockers, systematic literature review, tocolytic.

Contacts details of Regional Chairperson Elvira Lesmana rcindonesia@amsa-international.org +6285811240637

Nifedipine, Calcium Channel Blocker, as Tocolytic for Inhibting Preterm Delivery: A Systematic Literature Review of Randomized Controlled Trials Joue Abraham Trixie1, Abigail Serepina Siagian2, Mathilda Abigail Irianti3

1. Universitas Kristen Indonesia – (+62) 81574924922, joueabraham@gmail.com 2. Universitas Kristen Indonesia – (+62) 81314752976, serepinabigail@gmail.com 3. Universitas Kristen Indonesia –(+62) 81240314576, abigaelmarpaung@gmail.com

1. Introduction Premature is known as the birth of an infant alive before 37 weeks during pregnancy. 1,2 Towards the birth of subcategories of premature birth, ie, extremely preterm (<28 weeks), very preterm (28 to <32weeks), and moderate to late preterm (32 to <37 weeks). Globally, the premature births are number 1 cause of death in children under 5 years. 15 million babies are born prematurely as estimates. Nearly 1 million children die every year because of the premature as the complication. Many also survive, but live with disabilities.1 Disability such as respiratory disorders, eating disorders, cerebral palsy, growth disordes, visual disorders, and hearing loss.1,2,3 By 2015, 1 in 10 children in America, was born prematurely.2 Indonesia is ranked 5th out of 10 countries with the highest rates of preterm birth. 1 The government needs to improve antenatal care services to address this issue.4 The therapy that used to deal with early uterine contractions is by giving tocolytics. Tocolytic can endure pregnancy, so there is enough time for the lung maturation for the fetus. 5 Otherwise, there is sufficient time to obtain corticosteroids, in order to accelerate lung maturation in the fetus. 6 Tocolytic examples are mimetic beta groups, oxytocin receptor inhibitors, and calcium channel inhibitors. Each tocolytic has its own side effects and each pharmacodynamics.

The ideal tocoloytic should be effective, easy to use, no significant adverse effects on mothers and fetuses, and adequate for corticosteroids on antenatal services to reach the effects. 8 Beta mimetics are the most commonly used tocolytics. Reliable for pregnancy up to 7 days, no side effects on perinatal death.9,10 However, side effects can caused the mother, tachycardia and hypotension. Furthermore, about betamymetics is related to 25 cases of maternal death due to pulmonary edema.11 The uterus is a miogenic organ and this organ contracts spontaneously following the electrical wave activity resulting from membrane depolarization, ie the increase in intracellular calcium levels.3 Calcium channel blocker (CCB) blockers will prevent the calcium from outer cell get into the cell.12 Thus, a channel inhibitor commonly known as a hypertension drug that may prevent premature birth.7,12,13,14 The most common calcium channel blocker is the dyedropropyridine group, nifedipi. The first reported in 1980 nidedipine can act as effective tocolytics.15 Only at that time the tocolytic still cannot replace the betamymetics that used in clinical practice.1

Study Purpose 1. Find new ways to prevent preterm birth 2. Discuss whether calcium channel blockers can prevent preterm birth better than the existing tocolytics 3. Assess the efficacy and safety of calcium channel blockers, both in pregnant women and infants.

2.

Research Methodology

2.1.

Search Strategies A comprehensive literature search was conducted in October 2017 using the database such as PubMed Central, PubMed Health, The Cochrane Library, ScienceDirect, MedlinePlus, The Lancet, The Journal of Maternal-Fetal & Neonatal Medicine, dan Sage Journal. The combinations of terms used for the search included “Calcium Channel Blocker AND Tocolytic”, “Calcium Channel Blocker AND Pregnancy”, and “Calcium Channel Blocker AND Preterm delivery.” Where applicable and available, appropriate advance search techniques were applied to narrow the search.

2.2 Selection of Trials Inclusion Criteria: • Randomized, controlled clinical trials • Pregnant Woman at risk of preterm delivery within the range of 20 weeks to 36 weeks • Use calcium channel blocker, nifedipine as tocolytic The study was conducted within the period 2011 - 2017

2.3.Data Extraction The following data was extracted from the studies: 1.

2.

3.

4.

2.4.

Prolongation of Preganancy Maternal Side Effect Neonatal Side Effect Study Design: Population characteristics (Age, Gestational age, Cervical dilatation, Diagnosis of preterm labor), Intervention, Comparassion, and Outcome measurement.

Quality Assessment

The quality of controlled clinical trials was examined based on the method of Jadad, a method for assessing the quality of controlled clinical trials. Basic Jadad Score is assessed based on the answer

to the following 5 questions. The maximum score is 5. All of the criteria were scored with either yes or no. A “yes” was given one point, whereareas a “no” was given a score of 0.16 Two reviewers (JAT, ASS) independently analyzed the included studies based on the quality assessment criteria.

Question

Yes

No

1. Was the study described as random?

1

0

2. Was the randomization scheme described and appropriate?

1

0

3. Was the study described as double-blind?

1

0

4. Was the method of double blinding appropriate? (Were both the patient and the assessor appropriately blinded?)

1

0

5. Was there a description of dropouts and withdrawals?

1

0

Quality Assesment Based on Jadad Score

Range of Score

Quality

0–2

Low

3-5

High

3. Result 3.1. Research Findings and Study Selection The search team were applied to all of the 8 search engine and database mention earlier. Titles and abstracts were screened and relevant titles were selected. After removal of duplicates, a total of studies were obtained from the database search. Initial screening of abstracts against eligibility criteria excluded 5 studies. A further 10 trials were excluded after reading full text articles as they did not have a viable study design based on preset inclusion and exclusion criteria (Figure 1).

Therefore, this review includes 5 randomised trials testing the effects of CCB for tocolysis in preterm labour. A total of 621 pregnant women participated in the 5 trials. There were no placebo controlled trials identified. There were no trials in which a CCB was compared with no tocolytic agent.

The 5 included trials all compared results of tocolysis by a CCB, nifedipine with an alternative tocolytic.

The five clinical trials selected in this systematic literature review were conducted by Rezk M, et al. (2015)18, Nikbakht, et al. (2014)19, Vliet, et al. (2016)20, Bankatlal, et al. (2011)21, and Klauser, et al (2013)22.

Initial Search Results from Science Direct (n = 4)

Initial Search Results from PubMed Central (n = 135 )

Initial Search Results from PubMed Health

Initial Search Results from The Cochrane Library

(n = 29 )

(n = 1)

Initial Search Results from The Journal of Maternal Fetal & Neonatal Medicine

Initial Search Results from The Lancet (n = 4)

(n = 1)

Relevant Titles (n = 4)

Relevant Titles (n= 12)

Relevant Titles (n = 2)

Relevant Titles (n = 1)

Results of Database Searching (n = 22)

Relevant Titles (n = 1)

Relevant Titles (n = 2)

Studies After Duplicates Removed (n = 20)

Studies Screened (n = 20)

Studies Excluded (n = 5)

Full-Text articles assessed for Eligibility (n = 15 )

Full Text article excluded (n = 10)

Randomized Controlled Trials include in the Systematic Review (n = 5)

Figure 1: Flow Chart of Search

3.2. Quality of the Included Studies

From the result of this quality assessment, all 5 studies were defined as high quality studies, and can to be seen in the table below:

Table 1: Results of Quality assessment for the five studies Criteria

Rezk M, Nikbakth, et al. et al.

Vliet, et al.

Bankatlal, et al.

Klauser, et al.

1. Was the study described as random?

Yes

Yes

Yes

Yes

Yes

2. Was the randomization scheme described and appropriate?

Yes

Yes

Yes

Yes

Yes

3. Was the study described as double-blind?

Yes

Yes

No

Yes

No

4. Was the method of double blinding appropriate? (Were both the patient and the assessor appropriately blinded?)

Yes

Yes

Yes

Yes

Yes

5. Was there a description of dropouts and withdrawals?

No

No

No

No

No

Score

4/5

4/5

3/5

4/5

3/5

3.3. Participants

The characteristics of the participants included in these trials were clinically similar. The minimum gestational age at inclusion ranged from 20 to 28 weeks, and the maximum from 32 to 37 weeks. The mean gestational age at entry, when described, was between 28 and 34 weeks' gestation.

Preterm labor was reasonably consistently defined across the trials, most excluding those women with a cervical dilatation of greater than 4 cm. One trials included twin pregnancy

The standard indication for tocolysis were reported as inclusion criteria in the majority of included trials ; at least 2 times of contraction every 10 minutes or 4 times above 30 minutes or 3 times every 30 minutes or 4 times every 20 minutes. Cervical dilatation also includes preterm labor with an average of 0 to 4 for primers and 1 - 4 for multi. In twin babies dilatation can reach 6 cm. Preterm can also determinate via ultrasound.

3.4. Tocolysis Regimens Five trials compared oral nifedipine with other tocolytic agents. The other tocolytic was Indomethacin, Magnesium sufat, Ritodrine, Atosiban, and Nicorandil. Initial tocolytic therapy with nifedipine was administered orally. Initially, the initiation of nifedipine dose varied, from 10 mg to 30 mg in the first hour. Administration followed by maintenance dose. The maintenance dose is administered from 10 mg – 30 mg every 6 - 8 hours for the next 48 hours. In one clinical trial, nifedipine was administered until the age of gestation reached 37 weeks. One other clinical trial is given until the contractions stop.

3.5. Study Design and Characteristics Table 2 shows a summary of all the studies included in the inclusion criteria. All of the studies are followed by the same study and can be compared reliably. All study were double-blinded (except for Vliet, et al and Klauser, et al) and adequate randomized the subject. In all studies, only healthy pregnant women were selected.

Table 2: The Summary of Randomized Clinical Trials of The Five Studies Study

Population

Intervention

Comparassion

Outcome Measure

Rezk M, et al18

Age: 18 - 27 Years Gestational Age: 28 33 weeks

20 mg followed with 10 mg every 8 hours during 48 hours

Nicorandil, 20 mg given, followed with 10 mg every 8 hours during 48 hours

Nifedipine and Nicorandil are both successful in extending the gestation period for 48 hours. However, nicorandil tends to cause maternal and fetal tachycardia compared to nifedipine

10 mg, repeated every 20 minutes (for 1 hour maximum

Magnesium sulfate, given 10g (I.V) and 5g (I.M) every 4 hours.

Nifedipine and Magnesium sulfate are both successful in extending the pregnancy to

Cervical Dilation = 0 - 3 cm Diagnosis of preterm labor: 2 times uterine contractions with in a 10 minutes period in the 60 minutes Nikbakth, et al19

Age: 18 - 40 years

Gestational Age: - / + 40 weeks Cervical dilatation: 0 - 4 cm

dose is 30 mg).

Following a maintenance dose of 10 mg every 6 hours

over 7 days. Side effects given are not much different

Diagnosis of preterm labor: 4 times uterine contractions more over, each lasting at least 30 seconds Vliet, et al20

Age: 18 years Gestational Age: 25 34 weeks

20mg, followed by 20mg every 6 hours for 47 hours

Atosiban, given 20mg, followed by 20mg every 6 hours for 47 hours

Cervical dilatation: 1 - 3 cm

Nifedipine and Atoiban are both successful in extending the gestation period for 48 hours. The resulting perinatal outcome is not much different.

Diagnosis of preterm labor: 3 times uterine contractions per 3 minutes Bankatlal, et al21

Age: 22 years Gestational Age: 33 weeks Cervical dilatation: 1 - 3 cm

20mg is given every 8 hours to 37 weeks or until labor process occurs

Diagnosis of preterm labor: 4 times uterine contractions in 20 minutes

Klauser, et al22

Age: 18 - 26.5 years Gestational Age: 20 32 weeks Cervical dilatation: 1 - 6 cm Diagnosis of preterm labor: There is a

Nifedipine with initial dose of 30mg, followed by maintainance dose 20-30mg every 4-6 hours until contraction stopped

Ritrodrine of 100 mg (2 ampoules of ritrodrine containing 50 mg) was added to 500 ml of ringers lactate. The infusion was started at the rate of 50 g / min and increased by 50 μg every 15 minutes until the uterus stopped contraction. The maximum dose is 350 μg/ min.

Magnesium sulfate at a dose of 6mg (I.V) for 20 minutes, followed by maintaince dose of 4-6 mg every hour until contraction decreases <6 / hours before discontinuing the IV.

Nifedipine is more effective in prolonging pregnancy than Ritrodrine. The side effects are also less.

There was no significant difference between the three agents. Side effects of tocolytics and hypotension are more commonly caused by nifedipine.

contraction of the uterus for 5 minutes or less

Indomethacin was given as a 100mg suppository which could be repeated one time, two hours after the initial dose if contractions continued.

Followed by 50mg of oral indomethacin every 6 hours until contractions were extinguished for at least 1 – 2 hours

3.6.1 Study Outcome: Prolongation of Pregnancy The prolongation of pregnancy was primarily measured by the uterine contractions. The result show that the average of prolongation was 48 hours. The rest time is mean for pregnant women got kortikosteroid to maturity the neonates lung. Also nifedipine is more effective than the other tocolytic.

3.6.2 Study Outcome: Maternal Side Effect

The most maternal side effect was headaches, hypotension, and palpitations. It could stop the treatment. Blood pressure was measured each tocolytic administration.

3.6.3 Study Outcome: Neonatal Side Effect 3.6.3.1 Perinatal Death

3.6.3.2 NICU Admission

Out of the 626 babies who were born, 31 of them were dying. The causes include Respiratory Distress Syndrome, septicemia, intraventricular hemorrhage, bronchopulmonary dysplasia, sepsis, and necrotizing enterocolitis. In some infants may also experience meningitis, pneumothorax, apnoe, and asphyxia. But, in small quantities. Not all clinical trials examine the baby's weight.

Overall, the baby deliver with a weight of 1.008 grams up to 3000 grams. Hospital days overall is 1 to 73 days. Depending on the condition of the baby when born. The length of treatment depends on the baby's weight, apgar score, the need for ventilation, and the presence or absence of respiratory distress syndrome.

4. Discussion 1.1. Analysis of Results This systematic literature review will examine the usage of nifedipine (dihydropyridine class) as tocolytic in Preterm delivery. The writers will divide the table of research based on three parameters which are prolonged pregnancy, the maternal side effect, neonatal outcome after use of nifedipine based on previous clinical trials.25 Tocolytic is used to decrease the contraction of myometrium and being used in preterm delivery.

Tocolytic administration is important in preterm labor to improve the neonate outcome. Tocolytic will delay the preterm delivery so the healthcare can administer the antenatal corticosteroid to enhance the fetal lungs maturity. The lungs maturation decreases the probability of having respiratory distress syndrome in neonates.27 Myometrium contraction occurs because the increase of intracellular calcium (Ca2+). The voltage gated Ca2+ mediates the calcium into the cell causing cell depolarization and regulate the intracellular myometrium contraction.28 Nifedipine is the type 2 calcium channel blocker which will inhibit the calcium flows by binding into the L type slow calcium channel influenced by the Ca2+-activated K+ channels, beta-adrenergic receptors (β-ARs) and sexual hormones.25 The L-type calcium channels, which are widely expressed in cardiac and smooth muscles.26 Inhibition in this calcium channel prohibits calcium enter the cell, so the cell will not be depolarized. This causes the intracellular relaxation of myometrium.

Figure 2a shows the effectiveness of Nifedipine to prolonged the pregnancy for 48 hours to 37 weeks. The prolongation of pregnancy for 48 hours is comparable between the study (68% in Elvira Fliel, 90% in Jaju Bankatlal, 76% in Rezk M, 76,9% in {Nama penelitinya} and 8 % in Nikbakht).

Although nifedipine is effective in prolongation of pregnancy in 48 hours, the prolongation of pregnancy in 7 days shows a fewer number (51% in Elvira Fliel, 70% in Jaju Bankatlal, 71% in Rezk M, 56,9% in Chad K. Klauser) except for Nikbath’s research that shows more cases in nifedipine ability to prolong the pregnancy for 7 days (56%) than the 48 hours prolongation (8%). From all the literature reviewed, nifedipine is effective to be used in prolongation of pregnancy for preterm delivery.

Nifedipine causes several side effects in pregnant woman. The most common maternal side effect is hypotension (70% in M Rezk, 6.7% in Chad Cluster) followed by headache (70% in M Rezk and 20% in Juju Bankathal) and flushing. Nifedipine dilates the systemic and pulmonic blood vessels and decreases the arteries resistance. Besides, nifedipine also can decrease 20% of the systolic pressure, diastolic pressure, and mean arterial pressure.29 Those contribute in occurring hypotension in pregnant woman who use the Nifedipine as tocolytic. The vasodilatation effect of Nifedipine causes headache and flushing in patient. It is also reported that high doses of nifedipine (150mg / day) may cause severe dyspnea.26 However, maternal side-effects posed by nifedipine administration as tocolytic are few compared to other tocolytic agents.14 Of the 626 babies who were born, 31 of them were dying. The most common cause is respiratory distress syndrome. However, of all tocolytics that cause respiratory distress syndrome, the amount of respiratory distress syndrome induced by nifedipine is relatively less then other. Likewise with necrotizing enterocolitis, intraventricular hemorrhage, and neonatal jaundice.14,23

The Neonate Intensive Care Unit is more than 30% (37% in M Rezk, 55% in Banda Janju, 52.5% in Elvira Villet). Neonatal Intensive Care Unit is an intensive unit specialize for premature newborn infant, have low birth weight (<2,5 kg), or have a medical condition that requires special care. In preterm delivery, Nifedipine works by delay the delivery but the infants are still premature newborn. These infants are admitted into NICU to receive further medical treatment so that they can improve their health performance. The low birth weight in neonate happens because the infants were born before 42 weeks.

In the following research, they used nifedipine as tocolytic for 32-37 weeks gestational.

Based on the literature which are reviewed, The researches show that from 626 born infants, there are 31 cases of neonatal death (5%). The following causes of neonatal death are respiratory distress syndrome, septicemia, intraventricular haemorrhage, broncopulmonary dysplasia, and sepsis 5.

There’re some risk factors that can lead to neonatal death such as maternal age, gestasional age, the maternal hemoglobin rate, etc 6 .Certain mechanism also can cause the neonatal death despite the use of nidepine like prolongation of pregnancy can improve respiratory neonatal outcome but it can lead to fetal death due to circulatory problem.

1.2.

Limitations of Study Of all the clinical trials used, no trials discusses what dose will cause neonatal side effects.

Nor is any trials discussed the administration of nifedipine other than oral. There is also no recommended dose of therapy

1.3.

Future Research and Application The main purpose of using nifedipine as tocolytic is to extend the period of pregnancy, so there is sufficient time for administration of corticosteroids. Hope to speed up the process of lung maturation.

All types of tocolytic drugs are expected to achieve this goal, despite causing different side effects. The way these drugs work is also different - different. However, basically all tocolytic drugs works through intracellular signaling pathway. This allows the use of combined tocolytic drugs.

The combined use of tokolytics aims to increase the potency of tocolytics themselves. In addition, the combination of between tocolytic drugs will decrease the dose, so the side effects caused both in pregnant women and the neonatal will definitely decrease.13,24

4.4 Conclusion Calcium channel blockers, nifedipine can be considered safer and more effective tocolytic agents than other tocolytic. Also, the side effect is less than other tocolytic.

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32. Jehan I, Hillary H, Salat S, Zeb A, Mobeen N, Pasha O et al. Neonatal mortality, risk factors and causes: a prospective population-based cohort study in urban Pakistan. Bulletin of the World Health Organization 2009;87:130-138

MP-RELAXIN (Maternal Portable Relaxation Machine): Non pharmacological pregnancy pain innovation based on vibration, temperature and aromatherapy Fakhia Iffatunnisa1, Dedy Budi Kurniawan1,Mokhamad Fahmi Rizki S1 University Of Brawijaya

Abstract Pregnancy is a natural process for every woman. There are several things that cause discomfort such as Pregnancy-related Low Back Pain or Pelvic Gridle Pain. This pain can have a negative effect on the life of the mother because the mother will be bothered to perform daily activity. To reduce pain during pregnancy and childbirth, many therapies have been developed, both pharmacologically and non-pharmacologically. However, most of the pharmacological therapies have negative side effect for pregnant women and its fetus. The innovation of non-pharmacological therapy tools we propose can be a safe, easy to use, and inexpensive pregnancy pain reliever. This tool is expected to help relieving pain in pregnancy, so that pregnant women do not feel disturbed and can remain active. It uses vibrationbased technology, thermal temperatures, and aromatherapy combined into a set of device. The main components used in this tool are microcontroller¸ temperature sensor (DHT 11) which act as a heat controller, vibrator, and aromatic sprayer. The heat can be adjusted until the pregnant women is not bothered by the pain again. Frequency of vibration to produce relaxation effect can also be arranged according to individual body capability. Aromatic sprayer is active based on timer work. Every 5 minutes, the timer will trigger the microcontroller to command sprayer spray aromatherapy. This device is used in the medial part of the back of pregnant women. Frequency of vibration, aromatherapy, and hot temperatures can be adjusted by the user. In testing the effectiveness of the tool, Numeric Rating Scale (NRS) is used to calculate the degree of pain based on the questionnaire given before and after the use of the tool. In addition, the observation of pain is obtained by looking at the expression

of pregnant women. Target market MP-Relaxin is pregnant and maternal women who need quick treatment to overcome the pain of pregnancy and childbirth. Our current focus is product refinement, patent acquisition, and mass production. We will collaborate with IMERI, IBI, IDI, POGI, puskesmas, hospitals, posyandu, and even Kemenkes for socialization based on community. We use long term customer relationship method by connecting network user platform.

Keywords: Pregnancy pain, labor pain, non-pharmacological therapy, vibrator, temperature sensor, aromatic sprayer, Numeric Rating Scale (NRS).

Insilico and Invitro Study for Utilizing Active Compound of Thymoquinone in Decreasing NfKB and Increasing eNOS Expression in HUVECs Model of Severe Pre-eclamptic Pregnancies Alfryan Janardhana1, Savannah Quila Thirza2, Nicholas Kevin3, Kevin Marcello4 ASIAN MEDICAL STUDENTS’ ASSOCIATION BRAWIJAYA UNIVERSITY

Background: Preeclampsia is a syndrome in pregnancy and remains as the most common problem in maternal health.

In several studies, it has been discovered that the active compound of

Thymoquinone in black cumin (Nigella shativa) extract has anti-inflammatory effect. The aim for this research is to prove that the active compound of Thymoquinone in black cumin (Nigella sativa) extract can increase the expression of eNOS and decrease the expression of NfKB in HUVECs model with severe preeclampsia pregnancy.

Material and Methods: This scientific paper is based on experimental research (true experimental) that used post-test only control group design to measure the effect of treatment in comparison between experimental group and control group, without conducting a pre-test beforehand.

Exploration study uses Human Umbilical Vein Endothelial Cells (HUVECs) that is exposed with 2% of preeclampsia plasma in addition with Nigella sativa extracts in various doses. Insilico studies were done to test the pharmacokinetic and pharmacodynamics of Thymoquinone. In in vitro procedures, plasma was taken from 10 patients with severe preeclampsia and gestational age above 34 weeks that have signed inform consent.

Results: From Insilico result, it is found that the bioavailability of thymoquinone is notably high, which is above 70%. Thymoquinone will be absorbed 100% in the duodenum, thymoquinone then will enter the liver. Penetration of thymoquinone into the cytopasms of the target cells does not depend on pH value. According to the results in this study, it can be acknowledged that minimal dose thymoquinone will initially take effect on the inhibition of AKT and activate AMPK which will cause the increased expression of eNOS. From In vitro results, it is found that there is a decrease on NfKB expression and increase on eNOS expression on HUVEC samples which were exposed to thymoquinone beforehand. The higher concentration of black cumin (Nigella sativa) thymoquinone, the lower the expression of NfKB. While the higher concentration of thymoquinone, the more the expression of eNOS in the samples. A decrease in the activity of NfKB in patients with preeclampsia will increase proangiogenic factors and increase eNOS activity, both in endothelial cells of blood

vessels and in placental trophoblast cells. The result is the increased production of NO and improved endothelial function.

Conclusion: Therefore it can be concluded that Thymoquinone binds on the alosteric site of AKT and AMPK. The end result is increase in expression of eNOS and decrease in expression of NfKB

Pre-Conference Competition East Asian Medical Students’ Conference 2018 ABSTRACT

Integrated algorithm of postpartum hemorrhage management in developing countries: implication for reaching world’s fifth sustainable developmental goals Andrea Laurentius1 Nathasha Brigitta Selene2 Averina Geffanie Suwana3 Kresanti Dewi Ngadimin4

1Second Year Medical Student, Universitas Indonesia, (085372724042,

laurentiusandrea@gmail.com) 2Second Year Medical Student, Universitas Indonesia, (082112870839,

brigitta.selene@yahoo.com) 3Second Year Medical Student, Universitas Indonesia, (08111200259,

averinasuwana8@gmail.com) 4Second Year Medical Student, Universitas Indonesia, (08135206000,

kresanti.dewi@gmail.com)

Aim The purpose of this study is to evaluate the current preventive measures, diagnostic methods, and AMTSL guidelines from WHO, FIGO, and ICM to produce an integrated algorithm that would best accommodate the low health quality in developing countries, hoping that they could reduce maternal death up to 75%.

Background Postpartum hemorrhage becomes a significant global health issue as reducing 75% of maternal mortality is included in the world’s fifth Sustainable Developmental Goals (SDG). Guidelines provided by WHO, FIGO, and ICM in managing hemorrhage do not always adhere to conditions in some developing countries. Thus, improvement of management with PPH are important challenges encountered by governments and medical authorities. Possible method involving management of PPH executed optimally in these countries is raised as ultimate question.

Material and Methods Search engine PubMed was used to search for trials that assessed the prevalence, preventive actions, diagnosis, and prophylactic uterotonics of postpartum hemorrhage. Exclusion criteria are studies exceeding the last 15 years, irrelevant topics and data, and non-English journal.

Results Postpartum hemorrhage constitutes for the major causes of global maternal death. Each separated method, comprising preventive measures, early diagnosis, and prophylaxis administration, in managing PPH is combined into a single view of major algorithm would serve as basis in evaluating health sectors’ performance. Initial modification of previous single method could finally conform with the condition of world’s developing countries. In this case, integrated algorithm in PPH management could be applied in many confounding situations of developing countries for future goals in SDG. Conclusion High prevalence of maternal death in developing countries in the world suggests the inadequacy of maternal health services in hospitals. This condition has encouraged unification of separated and modified PPH management into a single algorithm fundamentally proposed for developing countries, consisting of preventive actions, antenatal care examination for prior diagnosis, and AMTSL drug prophylaxis.

Pre-Conference Competition East Asian Medical Students’ Conference 2018

SYSTEMATIC REVIEW

Integrated algorithm of postpartum hemorrhage management in developing countries: implication for reaching world’s fifth sustainable developmental goals Authors: Andrea Laurentius1

Nathasha Brigitta Selene2 Averina Geffanie Suwana3 Kresanti Dewi Ngadimin4

1Second Year Medical Student, Universitas Indonesia, (085372724042,

laurentiusandrea@gmail.com) 2Second Year Medical Student, Universitas Indonesia, (082112870839,

brigitta.selene@yahoo.com) 3Second Year Medical Student, Universitas Indonesia, (08111200259,

averinasuwana8@gmail.com) 4Second Year Medical Student, Universitas Indonesia, (08135206000,

kresanti.dewi@gmail.com)

Introduction Postpartum hemorrhage (PPH) is known as one of the most complicated situations during delivery. It is classically defined as after-labor blood loss for more than 500 ml although newer definition has been being proposed for further clarification. It could extensively disrupt maternal physiology which normally help mothers to fully adapt with the state of postpartum. PPH has predominantly caused maternal death all over the world, especially in low resource developing countries. Prevalence of PPH in several countries over the world is summarized in the following table 1 and graph 1.

Postpartum hemorrhage has become a significant global health issue as goal in reducing maternal mortality up to 75% is included in the world’s fifth Sustainable Developmental Goals (SDG).

Nevertheless, reaching this goal is difficult since the rate of maternal death in some developing countries are higher than ever before. Guidelines provided by WHO, FIGO, and ICM in preventing and treating postpartum hemorrhage do not always adhere to conditions in developing countries where the incidence of PPH is high. Diagnosis of postpartum hemorrhage before or during delivery is strictly encouraged to anticipate next steps in treating the event accordingly; however, application of advanced diagnostic tools and skilled primary care physicians towards PPH in some developing countries is not sufficiently provided due to several factors, such as uneven distribution of certified health workers across nation, limited political commitment, and inadequate financial resources. Moreover, unstandardized definition of postpartum hemorrhage diagnosis in developing countries could potentially marked errors in any data taken by hospitals for future references. Preventive actions, diagnostic examination, and prophylactic treatments of PPH are individually controlled as no clear integrated methods or algorithms are taken into practices. Improvement of management via prevention, diagnosis, and treatment for women with PPH are important challenges encountered by governments, as well as medical authorities in developing countries.1

Table 1. Prevalence of maternal death in developing countries.2-9

40

Prevalence of Maternal Death Worldwide 35

Prevalence (%)

30

25

20

15

10

5

0 Indonesia Malaysia Vietnam

Central Asia

India

Maldives Sri Lanka Uganda

Latin East Asia

American

Graph 1. Distribution of maternal death in worldwide developing countries.2-9

Considering any realities that maternal death in developing countries especially in low income countries is still high despite actions done by physicians, specialists, and government has come up to a proximate question. Is there any possible method involving management of PPH executed in developing countries optimally to further reduce maternal death? Elaboration of problems specifically to those aspects would not give potential solution, but observing the aspects in big picture might summon insights about integrated methods in reducing maternal mortality in developing countries. This integrated method in preventing, diagnosing, and treating postpartum hemorrhage prophylactically could offer better outcome regarding minimization of maternal death in developing countries in the world. As a result, this conjoined method could be optimally utilized as it is low-cost and practical.

Material and Methods Searches on PubMed database were made from 2nd October 2017 to 25th October 2017 in order to find potentially relevant journals for this systematic review. Types of study such as cohort studies, trials, cross-sectional studies, systematic reviews, and meta-analyses are eligible. Four separate searches have been done to be reviewed systematically using criteria of exclusion and inclusion in similar fashion.

Keywords used were “prevalence”, “maternal death”, “postpartum hemorrhage”, “cause”, “education”, “training”, “diagnostic”, “tools”, “active management of third stage of labor”, “carbetocin”, and “efficacy”. Exclusion criteria are studies that are not relevant after title and abstract screening, studies older than 15 years old, as well as data inadequacy. As much as 681 journals are finely selected into only 76 journals as they are the most closely associated ones.

Studies included for prevalence and cause of PPH

Studies included for second line of management

Studies included for the first line in management of PPH

Studies included for third line of management

Figure 1. Systematic methods in searching and selecting relevant literatures in database using PRISMA criteria.

Results and Discussion Postpartum hemorrhage should be etiologically recognized for its wide implications towards mothers and neonates. To understand the major risk factors that drive PPH, pointing causes of PPH could be made for constructing the method comprehensively. Frequent causes of postpartum hemorrhage comprise of uterine atony, genital tract trauma, retained placenta, coagulation defect, uterine inversion, and abnormal implantation of the placenta.1,10 Uterine atony or inadequate uterine contraction constitutes 70% major risk factors of PPH. Uterine atony is additionally reinforced by uterine overdistension, fetal macrosomia, or multifetal gestations.1 Furthermore, genital tract trauma comprises the second most probable cause of PPH which may result from lacerations of the cervix, episiotomy, or uterine rupture. Iatrogenic trauma such as cesarean delivery and instrumental delivery might also increase the risk of PPH.1 Retained placenta and clotting prevent adequate uterine contraction during delivery, inducing the probability of intrauterine hemorrhage.1 Other placental disorders, such as placenta previa and placenta accerata, widely corrupt the normal plane of placenta via overlying the internal cervical orifice and invading myometrium in uterus respectively.1,10 Special cases in either inherited or acquired hemostatic defects, as well as pre-eclampsia, alerts obstetrician and doctors to carefully assess maternal condition before delivery.11 For instance, intrauterine fetal demise with prolonged retention of a dead fetus, massive blood loss, amniotic fluid embolism, and sepsis, thrombocytopenia, von Willebrand disease are considered to be promoters of PPH risk factors.1,10,11

Table 2. The underlying causes of postpartum hemorrhage from the most to the least common ones.1,12

Clearly, suppression of postpartum hemorrhage incidence yields positive correlation with professional management of its underlying causes. Since developing countries often possess low-skilled workers and financial resources for health sectors, they are more susceptible to the incidence of the event. Thus, managerial measures in tackling its risk factors ought to be taken in facing the problems in order to minimize the events, as well as medical expenses in which the countries spend.

Management of risk factors in reducing postpartum hemorrhage Preventive actions towards health workers and pregnant mothers via simulation and education respectively: primary line of management

Simulation training for health personnel about PPH has been shown to improve the implementation of ICM/FIGO guideline in active third stage management.13 However, skilled health personnel are rare to find in even in developing countries.14 Furthermore, healthcare provider in underdeveloped countries has suboptimal knowledge of PPH risk, factors, diagnosis, and etiologies.15 Therefore, an effort to produce more skilled worker must be taken to overcome this problem. For example, training is required to address low level of knowledge of misoprostol registration and uses in low resource places.16 Training to healthcare provider especially in underdeveloped countries is needed as a low cost solution in preventing PPH incidence especially in low income countries.17 Simulation training program has proven to improve performance and skills about PPH.18 PETRA (Perinatal Emergency Team Response Assessment) scale is one of the methods in assessing team performance during obstetric crisis simulation. It is a valid and reliable tool to assess team dynamics to face obstetrics crises. 19 Data consisting training intervention and its results from several journals are summarized in the following table 3.

Table 3. Results of training intervention as preventive actions towards management postpartum hemorrhage. 20-27. tool to assess team dynamics to face obstetrics crises.19 Data consisting training intervention and its results from several journals are summarized in the following table 3.

Simulation-based training for either emergency maternal life support or delivery service substantially depressed the level of postpartum hemorrhage incidences. Considering the huge advantage of minimizing maternal death in a financial efficient manner, low-resource developing countries would be able to achieve the SDG goals in higher probability. Additionally, trainees consisting of primary health providers, physicians, or obstetricians are readily deployed to their maximal effort in caring pregnant mothers. Training-based educations done as preventive actions provide more permanent skills towards health personnel in managing the events. Effective distribution of prophylactic gestational drugs requires another educative action for mothers as unmonitored administration might cause maternal side effects, or even fetal abortion. Regarding effective reduction of PPH-associated death, secondary line of management besides preventive actions is required; that is proper antepartum diagnosis in detecting risk factors.

Prior diagnosis of pregnant mothers visiting for antenatal care: secondary line of management

Regarding the ultimate mission of WHO in accomplishing the fifth Millennium Developmental Goal, that is the reduction of maternal death up to 75%, several actions should be done in the first place to achieve the goal at both developed and developing countries in the world.28 Actions of public health in accordance with maternal and neonatal health will be the chosen representatives.

Education and preventive orders towards pregnant mothers, as well as reproductive female adults, serve as primary care system to minimize any risk factors related to postpartum hemorrhage. To

further reduce mortality and morbidity of pregnant women due to postpartum hemorrhage, rapid and accurate antepartum diagnostic tools are necessary to decrease the complication. WHO’s attempts to assess every maternal-fetal healthcare system in detecting PPH suspicions in the world have come to the usage of maternal near miss rate and mortality index.29 WHO has created sensitive algorithms in recording any cases related to maternal near miss death following disease, medical intervention, and organ dysfunction. Emphasizing the complication of organ dysfunction and lowering the threshold in transfusing blood during labor have caused higher detection in maternal near miss records since they can be used in varying patients’ conditions.30 Data of maternal near miss and mortality index in hospitals or healthcare system in several countries are summarized in the following table 4 and graph 2.

Table 4. Maternal near miss rate and mortality index in several countries for the required improvements.31-39

WHO's Maternal-Fetal Healthcare System Assessment 25

20

15

10

5

**

0 Tanzania Rwanda Uganda

Iraq

India

Egypt

Maternal Near Miss Rate (per 1000 live births)

Malaysia Brazil I

Brazil II

Syria

Mortality Index (%)

Graph 2. Maternal-fetal healthcare assessment in developing countries via WHO’s guidelines of maternal near miss rate and mortality index.31-39 (**) sign means no available data.

Healthcare system in several developing countries has not yet satisfyingly fulfill the criteria of maternal death reduction target, which is below 5% index. This view infers the low-quality of maternal health service provided in hospitals. In that case, hospitals or primary care centers in developing countries need to utilize much simpler, practical, and low-cost diagnostic methods.

Proper definition of postpartum hemorrhage should be strictly determined since it would offer as potential data in the future regarding its diagnosis. Postpartum hemorrhage is classically defined as loss of blood after or during labor for more than 500 ml. Nevertheless, this amount of lost blood may be tolerated by some women, in some cases, since the number was a cut-off where postpartum hemorrhage often causes maternal death.40 A new definition proposed for this condition would be the loss of blood in labor which reduces the hemoglobin concentration up to more than 2 g/dl or 10% of total Hb.40,41 Ensuring the usage of hemoglobin parameter would ignore the error of visual estimation. Qualitative visualization of blood loss estimation in postpartum hemorrhage is low in accuracy and precision. 42 To minimize the counter-effect that hemoglobin examination consumes time, low-cost blood pressure and shock monitoring machine could be utilized for any emergency situations regarding hemorrhage, establishing shock index in the machine as basis of treatment.43

Table 5. Ultrasound imaging usage in diagnosing pre-postpartum hemorrhage according to criteria.5665

Early detection of risk factors is essential in diagnosing postpartum hemorrhage. History medical records, uterine imaging, and peripheral blood tests provide significant data in reinforcing the detection.28,44-48 Pre-eclampsia, 44.5% of postpartum hemorrhage risk factors (OR = 1.53, 95% CI 1.461.6), can be examined via urinary adipsin rapid test, plasma uric acid, serum minerals, growth factors, and umbilical ultrasonography.28 Urinary adipsin test provides accurate diagnostic value of preeclampsia with sensitivity and specificity reaching 94.15% and 98.2% respectively. Its accuracy is 97.55%, and it is consistent with kappa value of 0.93 compared with gold standard.49,50 Elevated plasma uric acid or decreased serum zinc-copper are potential signs of pre-eclampsia along with gestational hypertension reading.51-53 VEGF and PIGF analysis in plasma also explains direct proportional to preeclampsia, indicating systemic inflammation during the condition.54 History of bleeding disorders, especially vWD type III, no antenatal care, and previous cesarean delivery (OR = 3) could initiate steps towards diagnosis of postpartum hemorrhage as they increase the risk of it.45-47,55 Further examination required to determine probability of future hemorrhage relies on low-cost ultrasound imaging technique.48 Utilization of ultrasound imaging in establishing criteria for postpartum hemorrhage diagnosis is included in the following table.

Ensuring proper diagnosis in antenatal care for pregnant women would dramatically limit the number of maternal death secondarily due to PPH. Cost-efficient methods in detecting PPH risk factors consisting familial disease history, peripheral blood examination, as well as sonographic assessments might offer inexpensive financial expenses in developing nationwide without altering their diagnostic accuracy. Not only direct risk factors discoveries are important, but also conventional medical definition of postpartum hemorrhage should be elaborated to the newer one to minimize bias in recording any of the events for future data. After management of its risk factors via diagnosis, tertiary line of management as part of goals in reducing maternal death would be uterotonic drugs for prophylaxis.

Active management of the third stage of labor in situational-effective state via prophylactic treatment: tertiary line of management

As a matter of fact, prevention of postpartum hemorrhage widely utilizes the Active Management of the Third Stage of Labor (AMTSL) which includes the prophylactic administration of uterotonic agents, controlled cord traction and uterine massage is recommended by WHO, FIGO, and ICM. Prophylactic administration with uterotonic substances, such as misoprostol, right before the predicted day of delivery would significantly protect women from PPH. Oxytocin is used as the first line of treatment due to its efficacy and few contraindications. However in low resource settings, the use of oxytocin is not feasible due to cost, and heat instability. Therefore, alternative uterotonic agents that could provide equal or greater results at a more efficient price point should be considered. Furthermore in low resource settings where there is an absence of uterotonics, controlled cord traction and uterine massage should be evaluated to analyze their effectiveness to provide better outcomes.

The route of oxytocin administration is important when it is the only intervention available; in which intravenous administration reduced hemorrhage risk by 76% compared to intramuscular administration (OR = 0.24, 95% CI 0.12-0.50). However in a condition where no uterotonic prophylaxis is available, controlled cord traction reduced post-partum hemorrhage nearly 50% (OR = 0.53, 95% CI 0.42–0.66) compared to no AMTSL components.66 As opposed to the AMTSL regimen in FIGO guidelines, uterine massage is associated with insignificant reduced blood loss of 0.1% to oxytocin administration alone and increased risk of post-partum hemorrhage. Therefore, it should be excluded.66-68 Oxytocin is currently the golden standard for the prevention and management of PPH, however it is not heat stable as it loses it potency in field conditions especially tropical countries. 69 Oxytocin must be stored in

controlled room temperature or refrigerated, therefore it is an impractical intervention in low resource settings where there is limited access to refrigeration. Carbetocin is a synthetic agonist analogue of oxytoxin, it induces a prolonged uterine response and is a stable molecule.70 Carbetocin is associated with lower mean blood loss of 34 ml than oxytocin, blood loss exceeding 500 ml was lowered from 18.4% to 25.8%, and fewer patients required additional uterotonics with 45.5% to 33.5% in oxytocin.71,72 Consequently, reductions in PPH rates and retreatments lead to the incremental cost effectiveness of carbetocin of US$278.70.73

The current formulation of carbetocin requires refrigeration, however a room temperature stable (RTS) variant of carbetocin is recently developed by Ferring Pharmaceuticals partenering with WHO.74 They have developed a new RTS carbetocin (Pabal) that have been approved by the EU Mutual Recognition Procedure. Pabal could be stored up to 300C with a shelf life of 24 months and 75% humidity, which could remove the necessity of refrigeration where it may not be available in low-income countries.75 A randomized trial of 30,000 women vaginally delivering in 10 countries on carbetocin RTS is currently being conducted to assess its non-inferiority against oxytocin.76 Health care personnel trained to perform safe intravenous and intramuscular administration of prophylactic uterotonic are not readily available in low resource countries. Therefore, a more practical alternative is the sublingual misoprostol 600 μg. However, its efficacy, and side effects against other uterotonics should be evaluated. Misoprostol is inferior to both oxytocin and carbetocin. Additionally shivering and fever are the most common side effects of misoprostol usage. 77,78 Using misoprostol in a community setting instead of no treatment in a chort of 1000 women would result in 22 preventable PPH cases but an additional 130 women experience shiver and 42 women with fever. However it is more cost effective compared to other prophylaxis with cost savings up to US$533. Although not the most preferable, by weighing the efficacy and the cost effectiveness of misoprostol, it is an effective and cost saving choice when there is no oxytocin available due to lack of skilled birth attendants.78

Integrated algorithm for management of postpartum hemorrhage in developing countries Suppose that each separated method in managing PPH is combined into a single view of major algorithm would serve as basis for health sectors in evaluating their performance. Initial modification of previous single method used internationally could finally conform with the condition of world’s developing countries. In this case, management of PPH might comprehensively be applied in many confounding situations, like low-skilled health workers, financial resource depression, and availability of health workers or physicians in care centers.1-3 The first line in the management of PPH includes risk factors prevention comprising fundamental obstetrics training based on simulations or scenarios for health workers and education of consuming misoprostol for mothers independently of physician availability in isolated area.18-27 Reinforced skills and knowledge of care providers would help them in confidently managing PPH event.22-25 Primary line in managing PPH would not be enough to reduce maternal death as PPH may suddenly appear as internal risk factors are not detected early. Overcoming this problem would be suited best with application of prior diagnosis for the missed risk factors alleviation in the beginning. Diagnosis in antenatal care for pregnant women is divided into family history analysis for certain inherited diseases, peripheral blood tests to serologically discover any anomalies during pregnancy, and uterine imaging via ultrasonography.52-60 Blood serology test and uterine imaging could serve as either complement or substitutive examinations alternatively. Corrected definition of postpartum hemorrhage should be proposed for more valid data regarding of PPH event in hospitals since their medical records are often used for incidence and prevalence calculation. 40,41 Any suggesting components that increase the probability of PPH have to be treated retrogradely with first line of management if mothers are still in pregnant state. Third line of management is applied only for mothers that are going to deliver their babies. Careful assessments of mothers’ condition according to the existence of major PPH risk factors must be done during the third line of management for correct uterotonic administration and cord traction in accordance with AMTSL.71-73, 75, 76 Uterotonic administrations are adaptively chosen regarding to conditions, except misoprostol for unskilled workers in doing both IV and IM injections.77,78 Algorithm for comprehensive management of PPH in developing countries is pictured in the following figure 2.

AMTSL Figure 2. Integrated algorithm in reducing PPH risk factors through three lines of management.3-8, 2025, 51-62, 70-78

Conclusion High prevalence of maternal death in developing countries in the world suggests the inadequacy of maternal health services in hospitals. Low-quality associated healthcare in these countries could be suspected for other sub-nation causes, such as lack of health workers attendance, unskillful physicians and obstetrics in treating PPH, limited governmental actions in improving maternal health sectors, and low financial resources. This condition has encouraged unification of separated and modified PPH management into single algorithm fundamentally proposed for developing countries. Maternal education and health worker training based on preventive actions are first line of management in reducing the incidence of PPH. Extra precautions for any risk factors silently occur in mothers are frequently done after prior diagnosis in antenatal care, such as history taking, blood tests, and uterine imaging. These could provide basic information to further assess the probability of mothers suffering PPH. Last line of management would be prophylactic administration of uterotonic and controlled cord traction. Associating all three lines of management in a single algorithm to reduce incidence of PPH might give huge picture of how developing countries can apply this integrated method into their problem in health sectors. Therefore, hope that developing countries could eventually accomplish the fifth sustainable developmental goal (SDG) will be realized in the future.

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The Importance of Adequate Macronutrient and Micronutrient on Pregnancy Outcome in Indonesia: A Systematic Review Attaufiq Irawan1, Farida Ulfa1, Woro Ayu Sekararum1, Nadifa Kartika Dewi1

1

Universitas Pembangunan Nasional “Veteran” Jakarta; Jl. RS. Fatmawati, Pondok Labu, Jakarta Selatan, 12450

Background Low birth weight and anemia is an indication of undernutrition in pregnant woman. Low birth weight percentage in 2013 is 10.2% and anemia percentage is 37.1%. These number is considered high since there is an insignificant decline in the percentage. This incident point out that the government specific intervention program regarding pregnant woman is not effective enough to overcome the problems mentioned in SDGs. The administration of adequate essential nutrition such as macronutrients and micronutrients has an important role in pregnancy health and fetus development. Both substance interacts through chemical reaction in order to sustain maternal health and fetus development. When one of the component is lacking or missing, the chemical reaction is halted resulting in a not optimal pregnancy output.

Aim Accompanied with many supporting data on the role of macronutrients and micronutrients, we analyze the role of both of this component and prove that both components is interrelated and needed to support pregnancy and fetus development.

Material and Methode Electronic search of PubMed, Nature, Springer, Scopus, Google Scholar, WHO, FAO and Unicef database was conducted. Outcomes of interest were birth weight, low birth weight, small size for gestational age, prenatal mortality and neonatal mortality. After exclusion of irrelevant or incomplete ones, 68 out of 157 articles were considered for the final analysis

Result Macronutrints and micronutrients is proven to be interrelated in supporting pregnancy and fetus development. Maternal and neonatal condition is related to dietary requirements of macronutrients and micronutrients.

Conclusion A balance intake of macronutrients and micronutrients results in a simultaneous process in the body.

Its benefits are marked in the human body, both of which are needed not only by pregnant women, but also by young women from the pre-conception or pre-pregnancy period resulting in better pregnancy outcomes. Foods that are considered taboo according to the local believes actually have good nutritional value and can support the continuation of pregnancy which indirectly support the fetus life thus, avoid both the mother and child from various health problems.

EAST ASIAN MEDICAL STUDENT’S CONFERENCE 2018

ASIAN MEDICAL STUDENTS’ ASSOCOATION – INDONESIA

SCIENTIFIC PAPER

The Importance of Adequate Macronutrient and Micronutrient on Pregnancy Outcome in Indonesia : A Systematic Review By:

Attaufiq Irawan, Farida Ulfa Woro Ayu Sekararum, Nadifa Kartika Dewi

FACULTY OF MEDICINE, UNIVERSITAS PEMBANGUNAN NASIONAL “VETERAN” JAKARTA

AMSA – UNIVERSITAS PEMBANGUNAN NASIONAL JAKARTA 2017

INTRODUCTION

Pregnancy is related to physiological changes that can cause higher plasma volume and red blood cells number while lowering the concentration of nutrients that binds to proteins and micronutrients. In several developing countries, physiological changes is worsen by the lack of nutrients intake resulting in micronutrient deficiency such as anemia. 1 Newborn mortality reflects the health development and human quality in a certain nation.2 Anemia is a problem faced by 38.2% pregnant woman across the world in 2011. Half of the incident is caused by iron deficiency3. The main cause of pregnancy anemia in Thailand is because of iron deficiency (43.1%)4. Studies in Malawi shows 32% percent of 150 pregnant woman suffer from iron deficiency and also one or more micronutrients deficiency5. In Indonesia, around 50% or 1 in 2 pregnant woman suffer from iron deficiency anemia 6.

According to data from Survei Kesehatan Nasional 2010, anemia in pregnant woman is as high as 40.1%. Whereas, according to Riset Kesehatan Dasar 7 in 2013 there is 37.1% anemic pregnant woman, which is pregnant woman with Hb value less than 11.0 gr/dL, with an almost similar proportion in urban (36.4%) and rural (37.8%) areas. Anemic pregnant woman is at risk of having low birth weight and preterm babies8. Pregnant woman is also at risk of having chronic energy deficiency, and deficiency of other nutrients, such as vitamin A, iodine, and zinc. Simultaneous nutrients deficient can cause a serious health problems to the mother and fetus6.

Nutrition plays a big role in maternal and child health 1. Poor maternal nutritional status will have an impact on the birth status; however, the relationship between maternal nutrition and birth status is determined by various factors. In Indonesia, pregnant women have a tendency to reduce the number of calories consumed, but it remains unclear whether this is caused by "foodtaboos"2 or there is a problem in the provision of food. Based on the adequacy of energy 3

, 53.9% of pregnant women experienced energy deficit (<70% AKE) and 13.1% had mild deficits (70-90% AKE). For protein adequacy, 51.9% of pregnant women had a protein deficit (<80% PPA) and 18.8% had mild deficits (80-99% PPA). Anemia2 in pregnant women is associated with increased preterm delivery, maternal and child mortality and infectious diseases.

In 2013, 10.2% of Indonesian infants experience LBW 9. The weight and length of the infant are affected by the nutritional status of the mother before and during pregnancy. Many pregnant women are deficient in some micronutrients, especially in developing countries. Among these numbers, iron deficiency has the highest prevalence. The risk of preterm delivery and LBW correlate with the incidence of iron deficiency anemia during pregnancy. A basic health survey in 2013 found that around 37.1% of pregnant women in Indonesia are anemic. The proportion of infant deaths in the neonatal period increased (38% in 2002), and the SDGs for child survival could not succeed without a reduction in infant mortality. Every year an estimated 4 million neonates die within the first 4 weeks of life. About 75%> Infant mortality occurs in low- and middle-income countries, the highest rate is in countries located in Central Asia. SGDs for child survival cannot be succeed without a reduction in infant mortality.

Sustainable Development Goals (SDGs) has become the reference for countries around the world to continue the eight years development program that should have been achieved by Millenium Development Goals (MDGs). SDGs will be established for 15 years and will be

ended in 2030. It is a continuation of MDGs’ goals that not yet been achieved, which is maternal and child health problems, access to clean water and sanitation, gender equality, women empowerment and nutrition status.

Prevalence of chronic energy deficiency in pregnant woman is raising to 24.9% during economy crisis. Although having a significant decline in post Indonesia economy crisis, the number is still considered high, which is 16.7%10. The high number of undernutrition in pregnant women give contribution to the high number of low birth weight in Indonesia, estimated 350.000 babies born with low birth weight every year 11. This result in high undernutrition number in school age groups. Data from Riset Kesehatan Dasar7 in 2013 shows that the prevalence of undernutrition has increase from 17.9% in 2010 to 19.6%.

To achieve the nutrition correction program, the government intervenes on improving nutrition in children and pregnant women by participating in Scaling Up Nutrition (SUN) movement12 or National Movement for the Acceleration of Nutrition Improvement by focusing in the first 1000 days of life which starts from the fetus period until the children is 2 years old13.

Preconception period is the best time for women to modify their dietary habits and select healthy nutritional patterns, the amount and quality of carbohydrates, protein and fat in diet may be important determinants of ovulation and fertility in healthy women, as suggested by recent studies.

National data on nutrition in pregnant women is very minimal, but the presence of low birth weight (LBW) and the incidence of anemia is an indication of undernutrition in pregnant women.12 in Indonesia, LBW numbers in 2013 had reach 10.2%, meaning that 1 in 10 baby is born with LBW. Riskesdas in 2013 found anemia in 37.1% of pregnant women in Indonesia, 36.4% of pregnant women in urban areas and 37.8% of pregnant women in rural areas 14 of total pregnant women of 5,415,256 incidents15 This fact point out that government specific intervention that focus on iron and folic acid supplement administration is not effective enough to overcome the problems in SDGs. Various references indicate that the provision of essential nutrients in the form of macronutrients and multiple micronutrients affect the health of pregnancy and fetal growth.

Macronutrients is a nutrient that is needed in large quantities and is generating energy such as, carbohydrates, fats, water, and protein, while micronutrients are nutrients that are needed in limited quantities that play a role in various chemical reactions in the body10. Increased intake of macronutrients, proteins, by 1 g during pregnancy may increase birth weight by 7.811.4 g, thus preventing LBW (Low Birth Weight)16. Increased fat intake in pregnant women affect the length of the baby born and LBW17. Micronutrients greatly affect the health of pregnant women and fetal development, if intake of micronutrients is inadequate it can cause pregnancy disorders, development, until the death of both mother and uterus 18. Multimicronutrient supplementation in pregnant women is able to decrease LBW: Low Birth Weight (LBW) and SGA (small for Gestational Age) events better than regular iron and folic acid supplementation 19,20. Folic acid is also known to reduce the risk of neural tube defects 21

. The absorption of micronutrient supplementation will be more effective when accompanied by macronutrient consumption such as fat, protein, and carbohydrate in measured levels22. Macronutrients and micronutrients interact with each other through

chemical reactions in favor of healthy pregnancy and fetus growth. When one component is lacking or absent, even chemical reaction cannot occur and the pregnancy outcome was not optimal.

Indonesia consist of thousand islands that inhibited by various ethnic groups and religions. Each ethnic grous and religion has different culture, language and food tradition. This food tradition is also known as “Food Taboo”. Food taboo is based on a system that comprises the religion and the believe towards god, the customs heredited from our ancestors and the knowledge we gained from formal education. Because of this believe, pregnant woman and neonatal are unable to gain different important nutrients, thus, resulting in lowered nutritional status.

There are 14 types of vegetables, 14 types of fruits, 10 types of fish, 5 types of meat, 3 types of fermented foods, palm sugar, jackfruit, pineapple, melinjo leaf, catfish, durian and ice cubes that is believed to give adverse effect towards pregnant woman and the fetus, therefore the consumption of this food is prohibited. For example, Jackfruit consumption is believed to create a dense lipid layer in the fetus, pineapple is believed to cause bleeding and seafood such as eel, fish and shrimp is believed to cause difficulty in delivery23. Moreover, durian consumption is believed to cause abortion, eggs are believed to cause longer pregnancy period and twin banana is believed to cause the fetus to be born overweight and sick23. This believe is supported by the fact that pregnant woman believe and obey what their mother and mother-in-law told them.

According to the data mentioned above, we decided to do a systemic review to analyze the importance of adequate macronutrients and micronutrients supplementation, correlated to the food taboo in Indonesia, towards the pregnancy quality in Indonesia.

1. MATERIAL AND METHODE The published results is from high-quality human observational and experimental studies which analyzed the effects of the administration of Multiple Micronutrients and macronutrient and their effect on the course of pregnancy and pregnancy outcomes were all included in this literature based analysis. Electronic search of PubMed, Nature, Springer, Scopus, Google Schoolar, WHO, FAO and Unicef database up to 2017 was conducted. Search was done in keywords: Multiple Micronutrients, MMN, UNIMMAP, Macronutrient, Micronutrient and Macronutrient interaction AND effect on pregnancy AND pregnancy outcome, food taboo in Indonesia. Our inclusion criteria are journal with: 1) intervention and observational studies, 2) have measurement before and after the baby delivery, 3) enclose MNCH (Maternal, Neonatal, Child health) indicator and 4) the study done in developing country. Our exclusion criteria are journal with animal study and review article From 157 publication that consist of journals and articles, we conclude 68 journals that correlate with our topic. We defined micronutrients according to UNNIMAP by WHO that consist of 15 micronutrients; macronutrients as carbohydrate, lipid and protein. Then we breakdown each of their biochemical functions in correlation with food taboo in Indonesia and the outcome in pregnancy.

2. RESULT We read and checked the abstract as a whole, we decided 7 journals to get into our systematic review. The seven entries are entirely intewatory studies that measure the effects of macronutrients and / or micronutrients on the MNCH indicator. A total of three studies discussing pregnancy loss, two studies discussing neonatal mortality and infant mortality, a study of preterm birth, five studies discussing anthropometry, two studies of motor development, and three studies of mental development. Key findings are described based on the outcome in the section below.

Pregnancy loss Keith P. West Jr et al.,(West Jr, Keith et al. 2014. Effect of Maternal Multiple Micronutrient vs Iron–Folic Acid Supplementation on Infant Mortality and Adverse Birth Outcomes in Rural Bangladesh: The JiVitA-3 Randomized Trial. American Medical Association) in his research found that Multiple micronutrient supplementation resulted in a non-statistically significant reduction in stillbirths (43.1 per 1000 births) compare to IFA supplementation (48.2 per 1000 births) [RR, 0.89; 95% CI, 0.81-0.99;P= .02]. Similar research conducted in lombok, Indonesia (Shankar, Anuraj. 2008. Eff ect of maternal multiple micronutrient supplementation on fetal loss and infant death in Indonesia: a double-blind cluster-randomised trial. The Lancet), shows that Combined fetal loss and neonatal deaths were reduced by 11% (RR 0·89, 0·81–1·00, p=0·045), and significant result to mother (RR 0·85, 0·73 – 0·98, p=0·022) or anaemic (RR 0·71, 0·58–0·87, p=0·0010). Similar studies in Indramayu showed similar results, whereas only 3.3% of the incidence of miscarriage, stillbirth, or neonatal death in MMN supplemented women compared with 6.9% who received IFA (Sunawang et al. 2009. Preventing low birthweight through maternal multiple micronutrient supplementation: A cluster-randomized, controlled trial in Indramayu, West Java. Food and nutrition bulletin).

Neonatal and infant mortality Early infant mortality was a reduction of 18% in mothers receiving supplemented MMN compared to those given IFA supplementation [35·5 deaths per 1000 livebirths vs43 per 1000; relative risk [RR] 0·82, 95% CI 0·70–0·95, p=0·010]. Infants whose mothers were undernourished (mid upper arm circumference <23·5 cm) had a reduction in early infant mortality is 25% (RR 0·75, 0·62–0·90, p=0·0021) and whose mothers were anaemic (haemoglobin <110 g/L) reduction in early infant mortality is 38% [RR 0·62, 0·49–0·78, p<0·0001] (West Jr, Keith et al. 2014. Effect of Maternal Multiple Micronutrient vs Iron–Folic Acid Supplementation on Infant Mortality and Adverse Birth Outcomes in Rural Bangladesh: The JiVitA-3 Randomized Trial. American Medical Association). Similar studies in Indramayu showed similar results, whereas only 3.3% of the incidence of miscarriage, stillbirth, or neonatal death in MMN supplemented women compared with 6.9% who received IFA (Sunawang et al. 2009. Preventing low birthweight through maternal multiple

micronutrient supplementation: A cluster-randomized, controlled trial in Indramayu, West Java. Food and nutrition bulletin).

Preterm Birth Preterm birth in mothers with MMN supplements was lower when compared to preterm birth in mothers with IFA supplements of 18.6 per 100 births compared to 21.8 per 100 births. (West Jr, Keith et al. 2014. Effect of Maternal Multiple Micronutrient vs Iron–Folic Acid Supplementation on Infant Mortality and Adverse Birth Outcomes in Rural Bangladesh: The JiVitA-3 Randomized Trial. American Medical Association)

Reference

Design

Location

Intervention/exposure

Outcomes

West et al.,

(n) Double

Bangladesh

Supplements containing

Stillbirth, preterm birth (<37 weeks), and low

2014.

blindedRCT (44.567)

birth weight (<2500 g)

Shankar., 2008.

Double

Lombok,

15 micronutrients or iron-folic acid alone, taken daily from early pregnance to 12 weeks Supplements postpartum of Iron and

Indonesia

Christian et al.,

blindedRCT (31.290) Double

Bangladesh

folic acid (IFA) or multiple micronutrients (MMN) Supplements of Iron and

neonatal mortality, fetal loss (abortions and stillbirths), and low birthweight.

Growth assessed longitudinally (from birth-24

Malawi

folic acid (IFA) or multiple micronutrients (MMN) Supplements of Iron and

months), cognitive function (at 24 months of ages) by using Bayley scales of infant and toddler developmentof– 11 third edition test.milestones Acquisition development

folic acid (IFA),multiple micronutrients (MMN) containing 18 micronutrients, smallquantity lipid-based nutrient supplements (SQ-LNSs) containing 22 vitamins and minerals, protein, carbohydrates, essential fatyy acids, Supplements of Iron and 188 kcal. folic acid (IFA) or multiple micronutrients (MMN)

monthly by maternal report, attainment of 7 motor milestones at 6, 12, and 18 monts of age, and assessment of motor, language, abd socioemotional deveopment and executive function at 18 months of age.

2016.

Prado et al.,

blindedRCT (8.529) Double

2016.

blindedRCT (869)

Sunawang, et

Double

Indramayu,

al., 2009.

blindedRCT (843)

Indonesia

Infant mortality (deaths ≤ 90 days post partum),

Fetal loss, neonatal mortality, and birthweight

Nguyen, et al.,

Double

2017.

blindedRCT (1599) Double blinded-

Dewey, et al., 2017.

Vietnam

Bangladesh

RCT (4011)

Weekly supplements of

Length-for-age z scores, motor development,

Iron and folic acid (IFA), folic acid (FA), or multiple micronutrients Supplements of(MMN, Iron and including IFA) lipidfolic acid (IFA),

cognition, language

Length-for-age z scores, head circumference stunting prevalence

based nutrient supplements (LNSs) or micronutrient powder (MNP) in four category: 1. women and children both received LNSs (LNSs-LNSs group), 2. women received IFA and children received LNSs (IFA-LNSs group), 3. women received IFA and children received MNP (IFA-MNP group), 4. women received IFA and children received no supplements (IFAControl group)

3. DISCUSSION

4.1 Macronutrition 4.1.1 Carbohidrate Carbohydrate has an important role in the body’s metabolic process, which is as an energy source24. Carbohydrate is grouped based on the amount of glucose unit and the bond that formed between the glucose components. The categories are sugars, starches and fibers25. Carbohydrate is broken down into glucose which will metabolized through glycolysis, resulting in pyruvate. Pyruvate is then converted into acetyl-CoA through citric acid cycle and thus, resulting in production of energy24.

Intake in pregnancy should produce enough energy in order to make sure the baby is

born in full term pregnancy with normal birth weight. Energy requirements in pregnancy is determined from the energy that needed to gain weight through pregnancy, this is correlated to the addition of fat and protein in maternal, fetus and placental tissue and from the elevation of energy demands for basal metabolism and physical activity26.

Energy requirements in the first trimester is increased by 180 kkal per person per day, in the second trimester is increased by 300 kkal per person per day and in third trimester is increased by 300 kkal per person per day27. Lack of energy intake will lessen maternal blood glucose28. This could influence the rate of fetus growth and subsequently influence the child birth weight. Reduced substrate level will cause elevation in growth-suppressive peptides secreted from the placenta which in turn reduced the rate of fetus development through decreasing the expression of insulin-like growth factor and elevating the binding proteins in fetus29.

Diagram 1. Carbohydrate deficiency

4.1.2 Lipid The need for fat in pregnant women increases with increasing trimester of pregnancy. In the first trimester there is an increase in fat requirement of six grams per person per day, in the second and third trimesters an increase in fat requirement of 10 grams per person per day30.

Fat from the diet, in the form of triacylglycerol will experience the process of lipolysis that produces glycerol and free fatty acids. Glycerol after going through two stages of the process into glyceraldehyde 3-phosphate can enter the glycolytic pathway directly and generate energy.

Fatty acids will be brought to the mitochondria in the cytosol where the βoxidation process occurs. β-oxidation will produce acetyl-CoA which can

Energy requirements in the first trimester is increased by 180 kkal per person per day, in the second trimester is increased by 300 kkal per person per day and in third trimester is increased by 300 kkal per person per day27. Lack of energy intake will lessen maternal blood glucose28. This could influence the rate of fetus growth and subsequently influence the child birth weight. Reduced substrate level will cause elevation in growth-suppressive peptides secreted from the placenta which in turn reduced the rate of fetus development through decreasing the expression of insulin-like growth factor and elevating the binding proteins in fetus29.

Diagram 1. Carbohydrate deficiency

4.1.2 Lipid The need for fat in pregnant women increases with increasing trimester of pregnancy. In the first trimester there is an increase in fat requirement of six grams per person per day, in the second and third trimesters an increase in fat requirement of 10 grams per person per day30.

Fat from the diet, in the form of triacylglycerol will experience the process of lipolysis that produces glycerol and free fatty acids. Glycerol after going through two stages of the process into glyceraldehyde 3-phosphate can enter the glycolytic pathway directly and generate energy.

Fatty acids will be brought to the mitochondria in the cytosol where the βoxidation process occurs. β-oxidation will produce acetyl-CoA which can enter the tricarboxylic acid cycle (TCA cycle) which will produce 1 molecule of FADH2 and 3 molecules of NADH. The molecule can be used to generate ATP by oxidative phosphorylation processes in the electron transport chain31. Acetyl-CoA is the main ingredient for cholesterol synthesis.

Sex hormones that play a role in pregnancy are all steroid hormones that are derived from cholesterol32. Cholesterol will be reduced to pregnenolone to be converted to progesterone and estrogen32,33 which play a role in pregnancy. Estrogen plays a role in pregnancy by making myohyperplasia of the myometrium, enhancing uterine vascularity, and helps stimulate contraction and mucous membrane secretion in the fallopian tubes.

Progesterone plays a fertilized ovum maturation, thickening of the endometrial wall, strengthening uterine contractions, and stimulating contraction and mucous membrane secretion in the fallopian tubes, and cervical hypertrophy34. Fats also play a vital role in brain development and CNS. DHA is a long-chain fat capable of penetrating the brain barrier through simple perfusion and will work on the membrane of neurons in the brain35. In neural membrane DHA will modulate the synthesis of phosphatidylserine (PS), increased PS levels in neuron membranes will increase the survival of neurons36. DHA acts as an influential neurobiological agent in membrane synthesis37.

4.1.3 Protein Proteins are nitrogen-containing compounds formed from amino acids of amino acids bonded with peptide bonds38.

Protein becomes the main constituent of body tissues, especially muscles. In addition, protein is also an important substance in producing hormones, enzymes, hemoglobin and can be used as a source of energy that is not main39.

The consumed protein will not be used if it is not hydrolysed in the protease or peptidase oeh being the simplest form of amino acid. There are 20 essential amino acids useful for the continuity of metabolism and growth, 12 of which are essential amino acids, amino acids that can not be synthesized by the body and can only be obtained through intakes from outside.

Essential amino acid acids are leucine, isoleucine, valine, lysine, threonine, tryptophan, methionine, phenylalanine and histidine.

Histidine is classified into essential amino acids because of the

Diagram 3. Mechanism of Amino Acid to Induce Insulin Secretion

harmful effect on hemoglobin concentrations observed in people given the histidine-free diet40.

Daily protein requirement is defined as a minimal intake that can make the balance of nitrogen in the body, according to the composition of the body when the energy balance and during physical activity is.

The daily requirements of proteins and amino acids are influenced by (a) dietary factors, (b) physiological characteristics of the subject (age, sex of genetic factor, circadian time, hormone, pregnancy, lactation and physical activity) (c) pathological conditions (infection, trauma, neoplasia, diabetes, obesity, cardiovascular disease, and fetal growth limitations) and (d) mental state factors (temperature, toxic agents, eating habits, and personal hygiene) Table 1. Dietary protein requirement by humans of all age group

Source : Recommended dietary allowance (RDA) published by the institute of medicine. FAO/WHO/UNU

Protein intake improves with pregnancy, this is because protein deposits are required and to maintain a balance of weight gain during pregnancy. The balance of weight gain in the third tri-mester is 0.66 g / kg per day. The safety limit of protein consumption corresponds to the average protein requirement under normal circumstances.

Protein deposition occurs mainly in the fetus (42%) but also deposits in the uterus (17%), blood (14%), placenta (10%) and chest (8%).

Unsubscribed proteins are not the same during pregnancy, most often there is a deposit in the early phase of pregnancy. An estimated 925 grams of protein are deposited along with a 12.5 kg increase in gestational weight gain (GWG). Protein deposition on the first trimerster is 36 gr, trimester 2 is 165 gr and in trimester 3 is 498 gr.

Diagram 3. Mechanism of Amino Acid to Induce Insulin Secretion If the increase in protein deposition is proportional to the increase in GWG then the total protein deposited will be 597 gr, which is distributed 1.6 gr / day and 6.5 g / day in the 2nd and 3rd trimesters.

Table 2. Recommended Additional Protein intake during pregnancy

a

Mid-trimester increase in weight x estimate average rewuirement (EAR) for maintenance protein for adult 0.66 g/kg per day b

Protein deposition adjusted for the efficiency of protein utilization during pregnancy : 42% c

Safe intake, calculate as the average requirement plus allowance for estimated coefficient of variation of 12%

4.3.1.1 Amino Acid and Insulin Insulin is a major growth factor in fetal41 because insulin mediates the increased production of IGF-1.

During the development of the fetus, beta-cell sensitivity to amino acids to insulin secretion occurs earlier than its sesitivits to glucose42. Amino acids become potent stimuli for insulin secretion and growth compared to glucose during early pregnancy. Amino acids have an important role in the excretion of insulin in pancreatic beta cells through the provision of action potentials on Ca2 + channels in the pancreatic beta cell membrane.

There are three main mechanisms that influence :

Diagram 3. Mechanism of Amino Acid to Induce Insulin Secretion

4.3.1.2 Arginine

Arginine can stimulate growth hormone secretion43. Growth hormone makes the fetus get more nutrients than the nutrients that pregnant women get44.

Arginine has the potential to trigger placental growth and development through polyamine45 synthesis trigger45. Compared with other amine acid types arginine is an important substrate in polyamine synthesis. Polyamine is the result of conversion from arginine to ornithine and then putrescine by ornithine decarboxylase (ODC).

Arginine can also stimulate insulin seritis. Decrease or lack of arginine and polyamine concentrations in fetal fluids and may produce intrauterine growth restriction46.

Diagram 4. Effect of Maternal Arginine

4.3.1.3 Leucine

Leucine has an effect to stimulate protein synthesis during fetus and postnatal life by providing a substrate for new protein synthesis, simultaneously stimulating to increase insulin concentration and play a direct role in stimulating the initiation path of translation.

Leucine also has great ability in increasing muscle protein synthesis through signaling pathway involving mammalian target of rapamycin (mTOR). mTor regulates the dissociation of mRNA translation by increasing phosphorylation of p70S6 kinase and 4EBP110.

TOR Complex 1 (TORC1) is a nutrient regulator comprising several subunit bags not limited to mTOR but comprising Rheb (RAS Homolog), raptor (regulatory associated protein) and PRES40 (repressor of mTOR activity) 48.

In addition leucine can also stimulate the secretion of insulin in the fetus and muscle protein synthesis and also regulate the mass of pancreatic beta cells. In beta cells pancras leucine activates mTOR through the mechanism of oxidative metabolism and by stimulating the metabolism of glutamate 49,50. Beta cell proliferation and formation of normal mass of pancreatic beta cells and their size.

Diagram 5. Effect of Leucine

4.2 Micronutrition 4.2.1 Vitamin A

Vitamin A is a fat soluble vitamin that can not be synthesized by our body, can only be found in food 51. Vitamin A is one of the subclasses of retinoic acid. There are 2 types of vitamin A52:1) preformed Vitamin A, found in meat, poultry, fish, and dairy products, 2) A provitamin, such as A carotenoids-β-carotene, αcarotene, and β-cryptoxanthin found in fruit, vegetable and plant based products. the most common provitamin A is β-carotene.

Vitamin A is required to perform normal body functions such as visual senses, maintain cell function for growth, epithelial integrity, red blood cell production, immunity and reproductive function. Due to the importance of vitamin A to our body, the requirement of vitamin A depend on body methabolism. Vitamin A deficiency can cause the most common (syndrome) of Xerophthalmia, growth disorder, and more susceptible to infection, leading to death.

Table 3. dayli requirement of Vitamin A

Age

Mean requirement

Recommeded

Group

(microgram

safe intake

RE/day) Infant and Childern 0 – 6 month 180 7 – 12 month 190 1 – 3 years 200 4 – 6 years 250 7 - years 330 - 400 Adolesence, 10 – 18 years 330 - 400 Adults Female, 19 – 65 years 270 Male, 19 – 65 years 300 Pregnant women 370 Lactating women 450 Source : Adapted from FAO/WHO, Rome 1988

(microgram 375 RE/day) 400 400 450 500 600 500 600 800 850

Bioavailiability Vitamin A contained in the plant is not sufficient in meeting the needs of Vitamin A body, so it takes animal intake to meet. And also WHO has recommended vitamin A supplement for pregnant women and children under 5 years because it has been proven to reduce mortality by 30%.

4.2.2 Vitamin E

Vitamin E is one of fat soluble micronutrient, an works as an antioxidant chain breaker, which we obtained from food. Vitamin E is also a complex antioxidant defense system to protect cells from the effects of cellular injury caused by endogenous and exogenous injuries53. Vitamin E increases the release of, a metabolite of arachidonic acid that inhibits platelet aggregation, decreases uterine contraction, and increases vasodilation of blood vessels thereby increasing the blood flow of the fetus and placenta called prostacyclin.

The term vitamin E covers eight fat-soluble compounds (α-, β-, γ-, δtocopherol, and α-, β-, γ-, δ-tocotrienol)54 and represented to different extents in fat-rich food, such as edible oils and seeds, or present in fortified food essentially as α-tocopherol55. All are derivatives of 6chromanol and differ in the number and position of methyl groups on the ring structure. The four tocopherol homologues (d-α-, d-β-, d-γ-, and d-δ-) have a saturated 16-carbon phytyl side chain, whereas the tocotrienols (d-α-, d-β-, d-γ-, and d-δ-) have three double bonds on the side chain. The most common isomer of vitamin E is αtocopherol, which positively related with increased fetal growth (birthweight for gestation), a reduced risk of small for gestation56.

Thus, emerging evidence suggests that circulating concentrations of vitamin E may be associated with increased fetal growth possibly via increased blood flow and nutrient supply to the fetus.

In summary, maternal nutrition and nutritional status before and duringpregnancy are associated with decreased birthweight and increased risk of low birthweight, measured either as preterm delivery or restricted fetal growth51.

4.2.3 Vitamin D Vitamin D3 (cholecalciferol) Vitamin D has an important role in the immune system57. Vitamin D deficiency is caused by a lack of sun exposure during pregnancy, as sunlight is needed to synthesize Cholecalciferol in the skin, as well as fish that contain high levels of oil58, as well as a lack of additional intake so it still does not meet the needs during pregnancy despite prenatal vitamins containing 400 IU vitamins59. And also have consumed additional nutrients60 such as (70% take a prenatal vitamin, 90% of fish, and 93% drank approximately 2.3 glasses of milk per day) 73% of the women and 80% of their infants were vitamin D-deficient61. Vitamin D deficiency can cause disturbed growth, skeletal disorders62, Diabetes, Asthma, Schizophrenia63, muscle weakness64, parathyroid hormone will be stimulated causing hyperparathyroidism9 which later can cause phospaturia65.

4.2.4 Vitamin C Vitamin C, or ascorbic acid and L-ascorbic acid are vitamins that we obtained from vegetables and fruit such as Citrus fruits and juices are particularly rich sources of vitamin C but other fruits including cantaloupe, honeydew melon, cherries, fruits, mangoes, papaya, strawberries, tangelo, watermelon, and tomatoes also contain variable amounts of vitamins C. Vegetables such as cabbage, broccoli, brussels sprouts, bean sprouts, cauliflower, kale, mustard greens, red and green peppers, peas, tomatoes, and potatoes may be more important sources of vitamin C than fruits.

Vitamin C works in tissue repair1. High doses of Vitamin C consumption can reduce the risk of stomach cancer 1. Vitamin C is also able to increase the absorption of non-heme iron by keeping iron in the form of fe2+. The antioxidant properties in Vit C are able to balance folate levels in foods and plasma, as well as increase excretion of oxidized folate derivatives in human scurvy2. When there is a deficiency of Vitamin C intake, the most common deficiency is Anemia, but In more severe condition, disease can be Scurvy may happen. During pregnancy, the Vitamin C needs increase, especially in the third trimester and 8-10 mg / day of vitamin C is needed to prevent scorbutic signs in infants.

4.2.5 Vitamin B1 Vitamin B1 or thiamin is an essential organic molecule that acts as a cofactor for enzymatic reactions, this vitamin can not be synthesized by the body but can be obtained from food consumed. The chemical name of thiamin is 3 - [(4-amino-2-methyl-5-pyrimidinyl) methyl] 5- (2-hydroxyethyl) -4-methylthiazolium consisting of pyrimidine rings and thiazole rings associated with methylene bridges.

Thiamin is a water-soluble vitamin absorbed through the intestinal transport system and processed in the liver, heart, and tissues. Thiamin will be converted into an active form of thiamin pyrophosphate in the brain and liver by a specific enzyme (thiamin diphosphokinase).

Thiamin is not stored body and its excess will be in urine excretion.

The daily requirement of thiamin is directly proportional to the food intake that is between 1.0-1.5 mg / d for adults. When there is an increase in carbohydrate intake, thiamin needs will increase.

Thiamin circulates in the body as free thiamin and some phosphorylated forms of thiamin mono phosphate, thiamin triphosphate and thiamin pyrophosphate / thiamin diphosphat.

Thiamin pyrophosphate is an active form of thiamin and acts as a co-

enzyme that plays a role in metabolism. Mini enzymes include the mitochondrial pyruvate dehydrogenase, the alpha-ketoglutarate dehydrogenase and cytosolic compounds of transketolase which all play a role in carbohydrate catabolism. Decreased activity of pyruvate dehydrogenase and alpha-ketoglutarate dehydrogenase leads to the failure of synthesis of adenosine triphosphate (ATP) and decreased selective ATP levels in the brain and may lead to cell death.

The association of vitamin B1 (Thiamin) with Protein (Aminno arginine acid) to angiogenesis in pregnancy mining NO is formed from a complex enzymatic process of nitric oxide synthase (NOS) of L-arginine and requires many cofactors. The role of NO in angiogenesis modulation. Angiogenesis is the process of formation of new, growing vessels endothelial that grow from preexisting capillaries. The process of angiogenesis begins with the dilation of blood vessels and is initiated by the vascular endhotel- cal growth factor (VEGF) produced in hypoxia. VEGF also plays a role in the proliferation of endothelial cells for the formation of new blood vessels. Nitric oxide is an important molecular signal as a vasodilator to increase vascular permeability and serves to control VEGF production. When much nitric oxide is produced it will show an increase in angiogenesis.

4.2.6 Vitamin B3 Vitamin B3 or often called niacin is composed of nicotinic acid (pyridine - 3 - carboxylic acid) and nicotinamide (pyridine - 3 Carboxamide. Nicotinic acid has a distinguishing effect with nicotinamide because of the ketone ketone receptor that also causes "flush response"66.

Niacin is produced from the biosynthesis process by tryptophan which is an essential amino acid found in protein67. Niacin is a term used for vitamin precursors to the formation of nicotinamide adenine

dinucleotide (NAD), while niacin is also the term for pushing nonvitamin NAD precursors68. The value of niacin equivalent is 1:60, each 1 NAD is produced requiring 60 tryptophan perkusors (http://lpi.oregonstate.edu/mic/vitamins/niacin). When high thryptophan is consumed it will produce a high NAD69. This process is a very long process and is considered less efficient in producing NAD but tryptophan metabolism plays an essential regulatory role by mediating immunological tolerance of the fetus during pregnancy70. It is now understood that tryptophan oxidation in the placenta drives a physiologic tryptophan depletion that impairs the function of nearby maternal T-lymphocytes and prevents the rejection of the fetus

Niacin has an important function in redox reactions that play a role in various metabolic pathways. More than 400 enzymes require niacin coenzyme (NAD and NADP) as electron receptors or donors70. NAD is most often used in reactions that produce energy or reaction solving (catabolism) from carbohydrates, fats, proteins and alcohols. The function of NADP is more frequent in biosynthetic reactions (catabolism) such as the catabolism of fatty acids and cholesterol70.

4.2.7 Vitamin B6 Vitamin B6 is a family of water-soluble vitamins that have a chemical structure of 2-methyl, 3- hydroxy, 5-hydroxymethylpyridines68. Vitamin b6 consists of pyridoxine (PN), Pyridoxal (PL) and pyridoxamine (PM), as well as its phosphate and glucosidal forms. The primary form of coenzyme formed by B6 is pyridoxal 5phospate, which is an important enzyme in more than 100 enzymatic reactions71 on the metabolism of proteins, lipids and carbohydrates68.

Vitamin B 6 also plays a vital role in one-carbon metabolism, facilitating cellular methylation processes, methionine recycling, regulation of homocysteine, and synthesis of cysteine.

Because vitamin B6 plays a role in many aspects of pathway metabolism, especially in protein metabolism causes an increased need for vitamin B6 as protein consumption increases72. Vitamin B 6 is widely distributed in foods of plant and animal origin. Muscle derived foods including beef, pork, chicken, and fi sh are good sources, and organ meats are particularly rich in vitamin B668.

4.2.7.1 The Role of Vitamin B6 in Homosistein Metabolism Vitamin b6 in pyrioxal 5-phosphate plays an important role in converting homocysteine to cysteine70.The first step of cystathionine beta-synthase (CBS) inhibits stimulation of Sadenosymethionine (SAM). Furthermore, cystathionine γlyase (CGL), catalyses the cleavage of cystathionine into cysteine and α-aminobutyrate forms. CGL inhibits

susceptibility to PLP loss during B6 deficiency. The production and concentration of cysteine are maintained at a wide range at optimum levels by vitamin B668 nutrients.

4.2.8 Vitamin B12 Vitamin B 12 or cobalamin is a corrin ring that contains cobalt.

Vitamin B 12 is only obtainable from microbial foods and vegetarian diet contains little vitamin 12. This vitamin is synthesize by microorganism and available in different chemical form in animal foods such as dairy, cheese and eggs73. In food, B 12 in bound to protein, and this binds break through pepsin gaster and acid activity.

B 12 will then bind to haptocorrin. Gastric parietal cells secrete acid and intrinsic factor. This intrinsic factor then will binds to B 12.

Most of vitamin B 12 absorption happen in the distal ileum through endocytosis74. Vitamin B 12 has an important role in methionine synthesis and L-methylmalonyl-CoA mutase.

Methionine synthesis happens through one-carbon metabolism cycle. This cycle is a reaction of addition, transfer or elimination of 1c unit in cellular metabolism. Methylation cycle that happen in the cytoplasm catalyze methionine through methionine adenosyl transferase and adenosine triphosphate to S-adenosyl methionine.

The last step of this cycle needs vitamin B 12 as a cofactor in methionine synthesis.

Inside the mytochondria, b-oxidation of fatty acid requires fatty acid to be broken down into even number carbon units, where the units

are binds by coenzyme A. This will allow then to enter the tricarboxylic acid (TCA) cycle. Metyl malonyl-CoA mutase is a B 12 dependent enzyme that reversibly isomerize methylmalonyl-CoA to suksinil-CoA75.

4.2.9 Folate

Folate is a water soluble vitamin that contribute in the methylation process which affect fetus and placental development76. The body cannot synthesize folate, the numbers of folate in the body depends on variety of intake from daily dietaries. Green vegetables, citrine and liver is a food rich in folate. Whereas food like bread, potato and dairy products contribute more to the total intake of folate even though they has less folate level. Folate from the food available in the form of 5-Methyl-THF and formyl-THF77.

Folate absorbtion happens in the jejunum. Vitamin-B12 dependent methionine synthase convert extracellular folate in the form of 5metyl-TF to monoglutamyl-THF, which is the intracellular form of folate that is used to synthesize nucleotides2. Since folate act as a coenzyme in one-carbon unit transfer, it function in cell differentiation and cell regulation78. 5 main pathway of one-carbon transfer that occur inside the cells are serine to glycine conversion, histidine. catabolism and thymidylate catabolism, methionine and purine synthesize77.

The majority of homocysteine is catabolized by Vitamin B6dependent enzyme cystathionin-b-synthase (CBS). This reaction convert homocysteine to cystathionin. Methionine synthase will regenerate homocysteine to methionine. This enzymatic reaction involve Methylene-tetrahydrofolate reductase (MTHFR) and vitamin B12 as cofactor79.

During pregnancy, low folate intake rising the risk for preterm birth and low birth weight80. Side metabolic effect of folate deficiency is a rise in homocysteine blood level (hyperhomocysteinemia)81 Hyperhomocysteinemia can cause the inhibition of eNOS (Endotel Nitrite Oxide Synthase) thus, resulting in lower nitrit oxide secretion by endothel cells. The low nitrite oxide levels will cause endothel damage which can limit the vasodilatation. This in turn can affect the growth of the trophoblast and implantation process82,83.

4.2.10 Iron Iron can be obtained from animals and plants sources in the form of haem and non-haem. Haem iron is available in meat, liver, poultry and fish. It comes from animals’ protein in the form hemoglobin and myoglobin. Non-haem iron is available in green vegetables, cereal and fruits. Both of these form of iron has different absorption rate.

Haem iron is absorbed faster than non-haem iron from vegetarian diet. It is absorbed around 20-30% from total iron intake. Non-haem iron absorption is around 5-10% from total iron intake84.

Globin-heme takes part in oxygen transport85. Heme is constructed in mitochondria where Fe2+ is incorporated into protophorphyrin IX. Most of the synthesized haem will be made into hemoglobin. Fetus hemoglobin has a higher affinity to oxygen than adult hemoglobin.

This allows fetus to obtain maternal oxygen through the placenta and 86

subsequently release it in the uterus with lower pO2 . Haem in the form of haem c is used as a cofactor to make cytochrome c.

Cytochrome c has at least one thioether bound that formed between cysteine protein and a vinyl group heme87. The purpose of transport electron that is formed is to generate proton gradient between inner membrane of the mitochondria thus, creating ATP88,89.

4.2.11 Zinc Zinc is an essential micronutrient that human need for metabolism.

Zinc needs increase in pregnant woman as the pregnancy age increases. In the third trimester the need for zinc increases to 10 grams per day per person. Zinc catalyzes more than 100 enzymes, facilitates protein folding, protects against oxidative stress, regulates gene expression, induces fetal growth through insulin-like growth factor-1 (IGF-1), and fetal brain growth, lowering preterm birth. Zinc deficiency in pregnant women can lead to miscarriage, preeclampsia and poor fetal growth due to decreased vascularization in the placenta. The development of hypocampus and cerebellum and autonomic system will also be disrupted in case of zinc deficiency.

4.2.12 Cooper Minimum copper requirement in pregnant women has increased by 100 mcg per person per day. Copper primarily works as a cofactor in metalloenzyme, as example ferroxidase. Ferroxidase serves to oxidase Fe2 + → Fe3 necessary to bind to transferrin for various needs of the body one of which is the formation of blood. Copper on the placenta acts as a superoxide dismutase that will prevent the body from oxidizing. Lacks of antioxidants in the body results in limited vascularization of the placenta, this may precipitate preeclampsia and impaired fetal growth. Copper helps the process of forming the structure of the kidneys, pankeras, and blood vessels in the fetus, in case of deficiency of copper it can occur disorders that later can causing cardiometabolic disease. Together with Zn, Fe, Cl, and iodine molecules will play a role in the formation of neurons in the brain and the CNS.

4.2.13 Iodine The minimal Iodine requirement in pregnant women increases by 70 mcg per person per day. Iodine is an essential component of the thyroid hormone involved in the regulation of various enzymes and metabolic processes. Iodine is necessary in the process of brain formation and CNS. In the placenta, thyroxin produced by the mother, able to penetrate the placenta and assist the process of brain development, CNS myelination. In the event of iodine deficiency it can lead to mental retardation, cretinism.

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LACK OF KNOWLEDGE AS A RISK FACTOR OF HIGH-RISK PREGNANCY IN SURABAYA, INDONESIA Azarine Neira Avisha Belinda Anasthasya Tansy, Nuruddin Dzulkarnain, Ika Puji Dana Savitri Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia

Introduction Until these days, Indonesia and other developing countries are attempting to reach the targets described in the Sustainable Development Goals (SDG) to reduce maternal mortality ratio under 70 per 100,000 live birth in 2030. Maternal and neonatal health is still one of the important factors that remains to be considered and reappointed in SDGs (Sustainable Development Goals), because maternal and neonatal health are indicators of a country's health status 1.

As of 2015, maternal mortality ratio in Indonesia was 216 per 100,000 live births. In fact, the MDG target for maternal mortality ratio in 2015 was 102 per 100,000 live births 2. The reduction of maternal mortality ratio in Indonesia was very slow and became a problem. In Indonesia, as one of the developing countries, inhibiting factors that influenced the slow decline in maternal mortality were social, economic and cultural factors 3.

The causes of maternal death are divided into two categories, direct and indirect causes. The direct causes are all factors associated with complications in labor and delivery 4. The indirect causes are all factors associated with complications in labor and delivery, which worsened the mother's condition 5.

One of the indirect causal factors that cause high maternal mortality is the existence of unfavorable pregnancy factors called “the four extreme”, including too young, too old, too much, and too close 6.

We can describe too young as the pregnancy at the age of less than 18 years. The reasons why it is not recommended to get pregnant at the age of less than 18 years is because at a young age, physically, the condition of the uterus and pelvis have not developed so that it can result in death of the mother and also her baby at the birth process. In addition, at that age, mental factors also can affect the child's development and mental healthiness of the mother 6.

Risks that may occur when pregnant women are too young are miscarriage, pre eclampsia, eclampsia, bleeding, congenital defects, low birth weight, and cervical cancer. These things can increase maternal and infant mortality 6 When a woman having pregnant over the age of 35, we called it ‘too old’. It is advisable to avoid getting pregnant over the age of 35 because at that age, maternal health conditions begin to decline and the quality of ovaries decreases. Moreover, the condition will increase the risk of miscarriage, pre eclampsia, eclampsia, difficulty in labor, bleeding, low birth weight and congenital defects 6.

“Too close” parameter means the distance between two pregnancies is less than 2 years. It needs to be avoided because the condition of the mother's uterus has not fully recovered. This condition may result

in pregnancy complications such as anemia, that may increase the risk of postpartum hemorrhage and intra uterine growth retardation. Moreover, the mother's attention to take care of two children who still need full attention is reduced 6. Risks which can happen when the gap of pregnancy is too close is miscarriage, anemia, heart trouble, premature babies, low birth weight, congenital defects, and not optimal growth of the infants 6 ‘Too many’ parameter means the number of children born is more than three. The reason for not allowing someone to give birth too many times is because it can lead to interruptions in pregnancy, such as placental disorders, growth retardation and increase the burden of the family economy. The risks that can occur when the mother has too many children are experiencing pre eclampsia-eclampsia, placenta previa, Low Birth Weight, and uterine prolapse 5. The Indonesian Demographic and Health Survey in 2002-2003 showed the indirect cause of maternal mortality was 22.4% of mothers had "the four extreme". Around 4.1% of pregnancies occurred in mothers younger than 18 years old (too young), 3.8% occurred in women over 35 years old (too old), 5.2% of births occurred in intervals of less than 2 years (too close) and 9.3% of pregnant women had more than 3 children (too many) 7.

Several breakthroughs in the reduction of Maternal Mortality Ratios and Neonatal Mortality Ratios in Indonesia have been done, one of the programs is the Birth Planning and Prevention of Complication Program which includes (a) the guarantee of midwives' competence, (b) guarantees of healthcare facilities and its capability to provide delivery assistance, (c) hospital in the sub-districts / cities capable of giving comprehensive service of obstetrics neonatal emergency (PONEK), (d) guarantee referral in cases of complications, (e) local government support for regulations, (f) Multi sector and community partnerships, (g) enhancing understanding and implementation of Birth Planning and Prevention of Complication Program 8.

Nevertheless, on its own implementation, the program may still have some obstacles. Based on the experience of the research program conducted by USAID on its assisted village, there were several factors that could prevent the success of the program, including 1) less involvement from cross-sectors such as religious affairs offices (KUA), education, and sub-district chief to become role model or messenger of health messages in Birth Planning and Prevention of Complication Program; 2) lack of understanding from both the pregnant mother and community about pregnancy and prevention of its complications 8.

Therefore, we conduct a research regarding the knowledge of the mothers about “the four extreme” as one of the risks causing maternal mortality. Our research was taken from two different angles, between coastal and downtown residents of Surabaya City. The goals of this research, included 1.

To measure mother's knowledge about “the four extreme” and its associated risk.

2.

To review the programs that have been implemented to reduce maternal mortality ratio.

The results from this research are expected to inform the government, as a evidence-based to manage the program, especially on monitoring and evaluating their program that have been implemented and increasing the awareness of all women about factors that contribute to maternal mortality. It is hoped that all these efforts can prevent maternal mortality.

Material and Methods

This descriptive study was carried out using a cross sectional design on 100 women who had children and lived in Surabaya, East Java, Indonesia. The demographic, knowledge and the pregnancy risks data were obtained using a questionnaire. All study participants agreed to sign the informed consent voluntarily. The research ethics approval was acquired from the Human Research Ethics Committee at Hang Tuah University (No. 8/M/KEPUHT/X/2017).

This research was carried out in two locations, in downtown Surabaya (central city district) and coastal area of Surabaya, to obtain the comparison between the data. We took the sample in Taman Bungkul in downtown area, which was coincided with the Car Free Day event. The main target of the first data collection was the people of Surabaya who were having activities at Car Free Day Event in Surabaya.

The second location was a coastal area of Surabaya, precisely in Kenjeran area. The main target in this second place was the residents who lived in the settlement by the Madura strait.

Results 1.

Mother’s knowledge about “the four extreme” Mother’s knowledge about “the four extreme” was as the following:

Figure 1 Mother’s Knowledge about” the four extreme” From Figure 1 it could be interpreted that from 100 study participants, 68 of them didn’t know about “the four extreme”, while 32 of them knew about “the four extreme”.

2.

The Characteristics of Mother’s Ages in their First Pregnancies

3.

The Characteristics of Mother’s Ages in their Last Pregnancies

2 T h e C h a r a c t e r i s t i c s o f M o t h e r ’ s

Figure 3 The Characteristics of Mother’s Ages in their Last Pregnancies

From Figure 3 we could see that almost all study participants had their last pregnancy at age 16-35 years old, which was categorized as having low-risk of “the four extreme”. But there were 14 study participants who had their last pregnancy when they were over 35 years old.

4.

The Characteristics of Pregnancies Interval

Figure 4 The Characteristics of Pregnancies Interval

From Figure 4 we could see that from all study participants, there were 10 people who were categorized as having high-risk of “the four extreme”, because their pregnancies interval was too close (less than two years).

5.

The Characteristics of Number of Children

Figure 5 The Characteristics of Number of Children From Figure 5 we could see that from all study participants, there were 6 people who were categorized as having high-risk of “the four extreme”, because their children was too many.

6.

Risk of “the four extreme” related to level of knowledge of mother

Based on the survey we got: ‘the four

‘the four

Total

Not Knowing about

extreme’12+

extreme’56-

68

“the four extreme” Knowing about “4

2

30

32

“terlalu” Total Study participants

100

From 100 study participants, 68 people did not know about “the four extreme”, while 32 people knew about it. From the 68 people who didn’t know about “the four extreme”, there were 12 people who were at risk of experiencing “the four extreme”. From the 32 people who knew about “the four extreme”, there were 2 people who were at risk of experiencing “the four extreme”.

We calculated the risk of “the four extreme” occurrence in mothers who did not have knowledge about “the four extreme”, when compared to the risk of “the four extreme” occurrence in mothers who have knowledge about “the four extreme”. The risk calculations was:

Risk = 2,82

From these calculations, it could be concluded that women who did not know about “the four extreme” had 2.83 times higher risk of developing a high-risk pregnancy, compared to women who knew about “the four extreme”.

Discussion Based on the research we have done, it was found that of the 100 study participants we interviewed, there were 35 people living in the city and 33 people living in coastal areas that did not know about the four extreme. A lack of mother's knowledge about the four extreme might contribute to maternal mortality ratio in Indonesia, because mothers were still confuse with their own preoccupations such as working and taking care of other household chores. This was a worrying fact where the mothers should have known about what was ‘the four extreme’, because it was important as it was one of many ways to reduce maternal mortality from indirect causes.

Actually, a lot of Indonesian government programs have been done to reduce maternal mortality.

However, based on USAID research that have been conducted on its assisted village, lack of understanding from society or pregnant mother about pregnancy and its prevention of complications, lack of cross-sector collaboration, such as religious affairs office (KUA), education and sub-district chief to become ambassadors or agents or messengers of health messages in labor planning programs (P4K) activities, and community involvement through forums or other groups has not been well managed by Primary Health Care 8.

From our research, there were 3 mothers who were pregnant at a very young age. Dangers that might occur in young mother were the premature birth, pre and post partum bleeding, miscarriage, pre eclampsia, eclampsia and congenital defects. Why we should prevent the pregnancies at very young ages was because, physically, the condition of the uterus and pelvis has not been well-developed that it could cause maternal mortality and also neonatal mortality in delivery of the babies6,9.

However, most women in both coastal and urban areas of Surabaya did not experience pregnancy under the age of 16 years. This could be attributed to higher education either in the urban area or the coastal area. This made women choose to have higher education rather than to get married. Surabaya’s government program that relieving the cost of education (free tuition fee) until the age of 17 years also supported the reduction of young pregnancies in Surabaya. What we expected was the higher the education level of the mother, the better their awareness of their health.

Someone will be categorized as “too old” when she has her pregnancies at over 35 years old.

From 100 study participants, there were 3 women who experienced their first pregnancies at age of more than 35 years old. In addition, there were still 14 women who experienced their last pregnancies at age of more than 35 years old. This condition was categorized as having a high-risk pregnancy that led to maternal or neonatal mortality.

Complications that occur in pregnant women at the age of more than 35 years old, mostly due to disruption of the vascularization system. The endothelial damage of blood vessels leads the disruption of

blood flows to the uterus. In addition, at that age, maternal health conditions weakened, the quality of ovum and ovary is reduced, and mother having risk of miscarriage, pre eclampsia, eclampsia, difficulties in labor, bleeding, low birth weight and congenital defects because the quality of eggs has also decreased due to the aging process.

The high number of women who held their pregnancies at very old age in coastal areas was also caused by the difficulty of having children with unknown reasons. Most of them did not go to a midwife, doctor or an obstetrician related to the problem. Factors that may affect the condition was their low education level. They thought that the condition was not a significant issue for their life. Whereas in the medical world, the definition of infertility is the inability of a couple to produce a conception when wife and husband are having intimate relation for 12 months.

We called a pregnancy is “too close” when the interval between two pregnancies is less than 2 years. In this parameter, there were 10 people from 100 study participants who had an interval between pregnancies less than 2 years. The interval between two pregnancies should be managed to prevent the complications such as anemia, fetal and position abnormalities, because the condition of the mother's uterus has not fully recovered. In addition, mother attention to take care for her children who need full attention is reduced so it can affect the child's growth and development 6,9.

We call a pregnant woman “too old”, when she has too many children (more than 3). The reason why we should prevents someone from having too much children is because it can lead to interruptions in pregnancy such as placental disorders, the development of the children are not optimal, and it can increase the burden of the family economy 6.

At the end of the MDGs era by 2015, WHO estimated an annual maternal mortality ratio reductions. Three countries with a Maternal Mortality Ratio of more than 100 approaching or exceeding the ratio of reduction between 2000 and 2015 were: Cambodia (7.4%; UI 5.4% to 9.5 %), Rwanda (8.4%, UI 6.5% to 10.6%) and Timor-Leste (7.8%, UI 5.7% to 10.2%) 2.

However, the calculation of global maternal mortality at the end of MDGs era reached 216 per 100,000 live births. In fact, the MDGs target for maternal mortality in 2015 was 102 per 100,000 live births 2.

Therefore, WHO applies possible strategies towards ending the preventable maternal mortality framework that defines five objective goals, including 1) addressing inequities in access to and quality of sexual, reproductive, maternal and newborn health care; 2) ensuring universal health coverage for comprehensive sexual, reproductive, maternal and newborn health care; 3) addressing all causes of maternal mortality, reproductive and maternal morbidities, and related disabilities; 4) strengthening heath systems to respond to the needs and priorities of women and girls; 5) ensuring accountability to improve quality of care and equity 2.

Many countries in the world have implemented the strategy. In Indonesia, many government programs have been implemented to reduce maternal mortality. Adjusting to the WHO program, by strengthening heath systems to respond to the needs and priorities of women and girls, Indonesia invested in the training of midwives and the creation of dedicated, village-level delivery points for maternal health service.

However, there are still many shortcomings related to the program implementation, which need to be evaluated. For example, public awareness about the program is still very low, including low interest from the community to follow the counseling held by the local Primary Health Care staff due to their business to work or something else.

The most influential role needed is the counseling from the professional healthcare workers. The effort that can be done to improve mother's knowledge about ‘the four extreme’ is to provide various counseling about it. Besides the counseling that have been conducted by healthcare staffs from each subdistrict, other things such as a promotion of family planning program to the new couple who will get married. This counseling can be done together with TT immunization or when the couple is taking care of the examination administration in Religion Affairs Office (KUA). Hopefully, after they get married, the occurrence of “the four extreme” which increase the number of maternal mortality can be reduced. When the programs can be mutually supportive and sustainable, hopefully it has a direct effect in reducing maternal mortality in our country.

Conclusion Women who did not know about “the four extreme” had 2.83 times higher risk of developing a high-risk pregnancy, compared to women who knew about “the four extreme”.

In Indonesia, many programs have been implemented to reduce maternal mortality, but they had to be reevaluated. High-risk pregnancy could be prevented to achieve maternal and neonatal health. We suggested some solutions, including high-risk pregnancy awareness campaign, the promotion of family planning program, and the prevention of young marriage. All the efforts should be carried out with cross- sector collaboration.

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KNOWLEDGE AND CONSUMPTION OF FOLIC ACID SUPPLEMENTS BEFORE AND DURING PREGNANCY ON WOMEN WHO LIVED IN DOWNTOWN AND COASTAL AREAS IN SURABAYA, INDONESIA Belinda Anasthasya Tansy, Azarine Neira Avisha, Nuruddin Dzulkarnain, Ika Puji Dana Savitri Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia

ABSTRACT

Aim The purpose of the study was to determine knowledge and consumption of folic acid supplements before and during pregnancy in Surabaya, Indonesia.

Background Of 7.7 million child deaths in 2010 worldwide, approximately 3.1 million were neonatal deaths.

Approximately 75% of neonatal deaths occur in the early neonatal period, or the first 7 days after delivery and 50% occur in the first 24h. As of 2012, Neonatal Mortality Rate (NMR) and Infant Mortality Rate (IMR) in Indonesia have declined to 15 and 26 per 1,000 live births, respectively. However, the decline did not meet the Millennium Development Goal (MDG) target, that was to reduce child mortality by two-third by 2015.

One factor that was known to have a significant role in reducing neonatal and infant mortality as well as preventing neural tube defects was the consumption of folic acid before and during pregnancy. Therefore, this important issue was elaborated in this paper.

Material and methods This descriptive study was carried out using a cross sectional design on 100 women who had children and lived in downtown and coastal areas of Surabaya, East Java, Indonesia. The demographic, knowledge and consumption of folic acid supplements data were obtained using a questionnaire. All study participants agreed to sign the informed consent voluntarily. The research ethics approval was acquired from the Human Research Ethics Committee at Hang Tuah University (No. 8/M/KEPUHT/X/2017).

Results Majority of study participants were housevives and their mean age was 41 years old. The chi square tests showed that women who lived in downtown area significantly had higher education attainment (94%) (p = 0,001), but they showed lower knowledge about the benefit of folic acid (30%) (p = 0,037). They were also less likely to consume folic acid before (36%) (p = 0,001). The consumption of folic acid during pregnancy was not sifnificantly different between women in downtown area and in coastal area (p = 0,059).

Conclusion Folic acid was very important for fetus and infant. However, the knowledge was rarely known by women in downtown area. Moreover, they were also less likely to consume folic acid before and during pregnancy.

Therefore, all health workers should disseminate the message and encouraging all women to consume folic acid before and during pregnancy.

KNOWLEDGE AND CONSUMPTION OF FOLIC ACID SUPPLEMENTS BEFORE AND DURING PREGNANCY ON WOMEN WHO LIVED IN DOWNTOWN AND COASTAL AREAS IN SURABAYA, INDONESIA Belinda Anasthasya Tansy, Azarine Neira Avisha, Nuruddin Dzulkarnain, Ika Puji Dana Savitri Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia

INTRODUCTION BACKGROUND Currently infant mortality rate (IMR) is still very high in the world. In 2016 data, we obtained that 46% of newborn deaths or neonatal comprises between below 5 years. The majority of all neonatal deaths (75%) occur in the first week of life and about 1 million newborns die within the first 24 hours. Globally 2.6 million children die in the first month. Newborn deaths around 7000 every day with one million people dying on the first day and reaching one million people died within the next six days. Nearly 80% of the major causes of newborn mortality include premature and low birth weight, infection, asphyxia (lack of oxygen at birth) and birth trauma.

According to the World Health Organization (WHO) Low Birth Weight prevalence is more common in developing countries and in families with low social economics estimated at 15% of all births in the world, the rate of LBW incidence in developing countries can reach 43% while in developed countries only reaches 10, 8 &. From the data obtained comparison between developing countries and developed countries 4: 1. Low Birth Weight is a newborn who weighs less than 2500 grams at birth. Low Birth Weight not only can occur in premature infants, but also in term infants who experience growth restriction during pregnancy.

Low Birth Weight problems, especially in premature infants occur due to immaturity of the organ system in the baby. Low birth weight infants have a tendency toward increased infection and susceptible to complications.

Giving prenatal folic acid administration to all women can also significantly decrease the incidence of neural tube defects. Since 1998, the Food and Drug Administration requires the enrichment of cereal grain products in such a way to be calculated so that the average woman consume an additional 200 μg of folic acid daily. In the United States the incidence of neural tube defects has decreased by a quarter after the enrichment of folic acid 1.

Defects with open neural tube defects include ancephaly, spina bifida, cephaloceles, and sparse fusion of spinal fusion (scysis). These neurulation defects occur in 1.4 to 2 per 1000 pregnancies and are the second most common form of birth defects after cardiac anomalies 1.

Women who have child with neural tube defects can reduce the risk of recurrence 2-5% more than 70% with folic acid supplements 4mg per day a month before conception and during the first trimester of their pregnancy 1.

In Indonesia, IFA supplementation for pregnant women has been a consistent national health policy and program since the early 90s. The program recommends that pregnant women in the second trimester take 60 mg iron and 0.25 mg folic acid daily for 90 days 2.

From the data above, the consumption of folic acid before and after pregnancy is very important to avoid various disabilities which can occur in the fetus. However, taking folic acid before pregnancy or during the pregnancy in a new partner has not become an important thing.

Most of them are not preparing for a pregnancy. In this research will be seen how the condition of people about the consumption of folic acid before and during pregnancy and also to know what factors play a role.

MATERIAL AND METHODS This descriptive study was carried out using a cross sectional design on 100 women who had children and lived in downtown and coastal areas of Surabaya, East Java, Indonesia. The demographic, knowledge and consumption of folic acid supplements data were obtained using a questionnaire. All study participants agreed to sign the informed consent voluntarily. The research ethics approval was acquired from the Human Research Ethics Committee at Hang Tuah University (No. 8/M/KEPUHT/X/2017).

RESULT The results of the study using several variables including the consumption of folic acid before pregnancy, the level of education, and the knowledges of the benefits from consuming folic acid and iron in urban and rural communities will be presented in the table containing the following graph.

Consumption Folic Acid Before Pregnancy

Yes No 82% 64%

36% 18%

Urban Coast

.

From Figure 1, we knew that 64% people in urban community consume folic acid before pregnancy, while 36% have not consumed folic acid before pregnancy. 18% respondents from coastal communities already consume folic acid to prepare their pregnancy, but as many as 82% haven’t consumed it yet. The awareness and knowledge about pregnancy preparation in coastal area is very low.

One of the important things that have an important role in the delivery of information about the benefit of the folic acid consumption to prepare the pregnancy is the educational factor. Here is the educational level data obtained with the assumption that low education is the maximum education junior high and higher education is a minimum of high school education.

Level of Education High Education

Lower Education

94%

55% 44%

6%

Urban

Coast

In figure 2, from the data from urban area, 94% of the population is highly educated and the remaining 6% is low education. As for coastal area, 44% of the population is highly educated while the remaining 56% in low education. In addition to the level of education of a community, public knowledge about the benefits of folic acid should also be known because higher education is not necessarily well understood about the benefits of supplements needed before or after pregnancy.

Here is the result of a survey on the level of community knowledge about the benefits of folic acid.

70%

KNOWLEDGE ABOUT BENEFI T ACID FOLIC Know

30%

34%

66%

Ignorance

URBAN

COAST

Figure 3 shows that 70% of people do not know the benefits of consuming folic acid, while 30% of them know the benefits of consuming folic acid. In coastal communities, as much as 66% of coastal communities do not know the benefits of consuming folic acid while the remaining 34% already know the benefits of consuming folic acid.

While during pregnancy most pregnant women taking part in Ante Natal Care with doctor or medical profesional. They told them the requirement of consuming folic acid.

Here is a graph that shows to know the level of consumption of folic acid during pregnancy in urban communities and coastal communities.

CONSUMPTI ON FOLIC ACID W HILE PREGNAN CY Yes

No

100%

90%

82%

50% 10% 18% Urban 0%

Coast

In Figure 4 folic acid consumption during pregnancy in urban community as much as 90% have already consumed folic acid while the remaining 10% have not consumed folic acid. In coastal communities as much as 82% have already consumed folic acid while the remaining 18% have not consumed folic acid during pregnancy.

It find out whether the special community of his mother just consume folic acid without knowing the benefits

DISCUSSION Majority of study participants were housevives and their mean age was 41 years old. In Figure 1, from the data on coastal area, the consumption of folic acid before pregnancy, the respondents who were not consuming folic acid before their pregnancies obtained a high rate (82%). Meanwhile, in downtown area, there are 64% of the respondents who were preparing for pregnancy by taking folic acid before pregnancy. The chi square tests showed that women who lived in downtown area significantly had higher education attainment (94%) (p = 0,001), but they showed lower knowledge about the benefit of folic acid (30%) (p = 0,037)

They were also less likely to consume folic acid before (36%) (p = 0,001). The consumption of folic acid during pregnancy was not sifnificantly different between women in downtown area and in coastal area (p = 0,059). It shown in the data that there are 30% respondents from the downtown who were consuming folic acid during their pregnancy, and there are 36% respondents from the coastal area who were consuming folic acid during their pregnancy.

Folic acid is a B vitamin that, if taken before and during early pregnancy, can help prevent neural tube defects (NTDs), which are major birth defects of the baby’s brain and spine. Since 1998, the Food and Drug Administration of the United States have required the enrichment of cereal grain products in such a way to be calculated so that the average woman consume an additional 200 μg of folic acid daily. In the United States the incidence of neural tube defects has decreased by a quarter after the enrichment of folic acid.

In China, there was a 54% reduction in early neonatal mortality in women who received iron and folic acid supplements compared with folic acid alone. There was also an increase in the duration of gestation with a significant reduction in risk of early preterm delivery2.

A meta-analysis of three randomized controlled trials of folic acid supplementation for pregnant women in Asia, North Africa and sub-saharan Africa indicated that both folic acid supplementation and fortification were effective in reducing neonatal mortality from neural tube defects.

In Indonesia, iron and folic acid supplementation for pregnant women has been a consistent national health policy and program since the early 90s. The program recommends that pregnant women in the second trimester take 60 mg iron and 0.25 mg folic acid daily for 90 days1.

A retrospective cohort study of the Indonesian Demographic and Health Surveys Data of 2003 to 2007 indicated that antenatal iron and folic acid supplements prevented neonatal deaths in Indonesia3.

There have been available health policy on the use of iron and folic acid supplements as well as fortification in Indonesia, and there have been evidence-based medicine that antenatal iron and folic acid supplements prevented neonatal deaths4. On the contrary, majority of women in this study had poor knowledge and lack of consumption of folic acid supplements before and during pregnancy.

CONCLUSION Consumption of folic acid in pregnant women has been effective when the mother did ANC, because midwives and doctors ask the mother to consume folic acid. However, for pre-pregnancy preparation by taking folic acid is still very poor because of the lack of knowledge and awareness of coastal communities. A. Therefore, all health workers should disseminate the message and encouraging all women to consume folic acid before and during pregnancy.The effort that can be implemented to improve the level of consumption of folic acid in the mother to prepare for pregnancy is to provide a variety of counseling.

REFERENCES

1. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, et al. Williams Obstetrics 24th edition. 2003.

2. Dibley MJ, Titaley CR, Agho K. Iron and folic acid supplements in pregnancy improve child survival. 2015;(C).

3. Statistics Indonesia (Badan Pusat Statistik [BPS]), National Population and Family Planning Board (BKKBN), Indonesia Ministry of Health (Depkes RI), ICF International. Indonesia 4. Demographic and Health Survey 2012. … Heal Care [Internet]. 2013; Available from: http://www.dhsprogram.com 5. Kementerian Kesehatan RI. Fortifikasi Tepung Terigu. 2003;(962).

REVOLUTIONARY MALARIA IN PREGNANCY THERAPY USING ALLICIN FROM GARLIC EXTRACT(ALLIUMSATIVUM): BIOMOLECULAR STUDIES USING IN SILICO Fakhia Iffa Tunnisa1, Dedy Budi Kurniawan1, Mokhamad Fahmi Rizki S1, Editya Fukata1 University Of Brawijaya

Abstract Malaria is an endemic disease that can lead to death. Malaria in pregnancy is a major contributor to maternal and neonatal morbidity and mortality. The malarial control and management can be threatened by antimalarial drug resistance and adverse effect, in this way renewable therapies are needed to overcome this disease. The surface of sporozoites has a major protein called circumsporozoite protein (CSP), which is played by cysteine proteases during invasion process of host cells. Inhibition of cysteine protease will prevent invasion of host cells. Garlic extract contains allicin which has the potential to be a malarial disease therapy. Th aim of this study is to know about effectifity allicin toward as malaria in pregnancy. The author uses 2 methods of systematical review and in silico methods. A study of the systematical review was conducted to prove the consistency of the results of in silico. The searching of literature study used the three major search engines: NCBI, Sciencedirect, Clinical key with the keywords "allicin", "garlic", "plasmodium falciparum", "antimalaria", "cysteine protease" in vivo ", in vitro". research published in 5 years (2012-2017) and English literature. The method in silico uses cysteine protease sequences obtained from uniprot and pubchem data. The results of the insilico method show that allicin is able to bind to the active site of protein cysteine protease enzyme that plays a role in host cell invasion The active side of the protein enzyme cysteine protease binding to allicin is alanine 206 with a bond strength of 3.7 kcal/mol as the highest value and -3.3 Kcal/mol as the lowest value. Sporozoit treated with allicin 10μM, 25μM, and 50 μM dosage for 10 minute, allicin was diluted 12-times, and then diluted sporozoite and allicin were added to the cell.

Allicin can be given by oral administration because it has a good amount of biovability and allicin has high quantity of log p, hance it become lipophilic property. Allicin is also safe for pregnant women proven by positive effect on birth weight and higher values of internal organ of animal model.

Keyword : Allicin, Malaria pregnancy, cystein protease, In Silico

HAVE YOU HEARD, MOM? A Systematic Review about the Possibility to Increase Maternal Education by Mass Media Exposure in Order to Decrease Maternal and Neonatal Mortality

Authors :

Fernando Mario Regina Rachel Gunawan Vincent Lau Vincentius Dennis Prabaniarga

YOGYAKARTA 2017

ABSTRACT

I. Background The third SDGs (Sustainable Development Goals) is to reduce the maternal mortality by less than 70 per 100,000 live births and the global neonatal mortality to be less than 12 deaths per 1000 live births by 2030.

To achieve SDGs, Indonesian government has implemented Antenatal Care which shows high participation number according to Profil Kesehatan Indonesia 2015, but even so why the maternal mortality in Indonesia is still above 300 per 100.000 live births? We suggest loopholes in the quality of the maternal health service, especially in how to educate patient. In developing countries, maternal education is only shared by doctor and by oral health education, not by other means such as mass media.

One of the the way is through Mass media, and to know how effective mass media could be, we decided to do systematical review about the impact of Mass Media to mother utilization of skilled Healthcare worker help for delivery, exclusive breastfeeding and Antenatal Care (ANC) participation

II. Material and Method We use systematic review of cross sectional studies from databases : PubMed, PMC, Sciencedirect, etc, according to the inclusion and exclusion criterias we had determined. The keyword used are “Mass Media” AND “Maternal Health”, and critical analyzed with CEBMa checklist for cross sectional study and for statistical analysis we used MedCalc . The writing structure are based from combination of PRISMA and PCC EAMSC Guideline.

III. Result We screened about 278 records and finaly odo 3 meta-analysis according to the factors affecting maternal health with 6 last records. The overall OR of exclusive breastfeeding is 2,34 (95% CI 1.984 to 2.768, p <0,05 ), OR for ANC Participation is oodd ratio is 2,78 ( 95% CI 2.076 to 3.718, p <0,001 ), and overall Skilled Healthworker Help for delivery odd ratio is 3.46 ( 95% CI 2.968 to 4.025, p <0,001 ). The result proves that mass media has significant positive effect to the factor of maternal health.

IV. Conlusion Mass media has significant positive effect on exclusive breastfeeding, skilled healthworker help for delivery, and ANC participation. It shows that mass media holds vast potential for increasing the maternal health through education.

HAVE YOU HEARD, MOM? A Systematic Review about the Possibility to Increase Maternal Education by Mass Media Exposure in Order to Decrease Maternal and Neonatal Mortality

Authors :

Fernando Mario Regina Rachel Gunawan Vincent Lau Vincentius Dennis Prabaniarga

YOGYAKARTA 2017

CHAPTER I INTRODUCTION

I.I. Objectives This research is done in order to: To explore the impact of maternal education through mass media on maternal and neonatal health factor To give the appropriate recommendation on how to overcome the high maternal and neonatal mortality in Indonesia by using the mass media

I.II. Background Since January 1st 2016, United Nations had established the Sustainable Development Goals (SDGs) in which the maternal and neonatal health care is included in the third goal. The global maternal mortality is expected to be less than 70 per 100,000 live births by 2030 and the global neonatal mortality to be less than 12 deaths per 1000 live births. Particularly in developing countries, significant strides have been made in order to increase the life expectancy and reduce some of the common killers associated with maternal and neonatal mortality.

Indonesian government has implemented Antenatal Care, like the other developing countries, in order to decrease the maternal and neonatal mortality. According to Profil Kesehatan Indonesia (2015) the number of mother participation in Antenatal Care in Indonesia has reached 95.75% for the first and 87.48% for the fourth (last) visits. As we can see, the participation in the Antenatal Care is already at a satisfying level. However, the maternal and neonatal mortality is still high and hasn’t showed any sign that it’ll reach the SDGs. Why don’t the maternal and neonatal mortality decrease even though the participation in Antenatal Care is already good?

This paradox shows that there is a problem in the quality of the maternal and neonatal health service.

There are many risk factors associated with increased in maternal and neonatal mortality, one of the most important risk factors in the developing country is the maternal education. Lack of mother’s knowledge about the appropriate maternal education is associated with high maternal and neonatal mortality.

In Indonesia and other developing countries, health education is only shared by Doctor and by oral health education, but this conventional method doesn’t seem to be effective in increasing the Maternal and Neonatal Health. So, how do we overcome this lack of maternal education in developing countries? What other method can we do to fill in the knowledge every mother should know? What method is the best and the most efficient in increasing this maternal

education? What can we make use of to fill in the gap? The gap hole in utilizing the health education is the use of mass media.

The mass media in any society within which they function play roles that are germane to the development of that society, and of the members within the society, thus creating a social ecosystem that in turn impinges on the operations of the mass media. Mass media, as the phrase implies, are mass-based pathways to reaching a mass audience that comprises people of varying backgrounds, who need the media to keep up with the pace of events around them. The use of mass media nowadays differs from one household to another; some use it for entertainment, media for communication, to know about things which happen around them, etc.

And between the endless lists of the advantage to use mass media, mass media is also known as a place to gain knowledge about many different things.

Mass media is often used to give information about smoking cigarette, narcotics, and also BPJS (Badan Penyelenggara Jaminan Sosial), while information about maternal and neonatal health has never been touched even though the quality of the country next generation is determined by a good maternal and neonatal health even before the pregnancy until the 1000th first day of birth (1000 Hari Pertama Kelahiran). By using the exposure of mass media to increase maternal education about nutrition education, family planning, utilization of Health Service, breastfeeding and Antenatal Care (ANC), the maternal mortality in developing countries can be suppressed to the minimum.

To answer the questions we have list above, we decided to do a systematical review about the use of Mass Media exposure to increase maternal knowledge about nutrition education, family planning, utilization of Health Service, breastfeeding and Antenatal Care (ANC), to know how effective mass media can be, and to know if this intervention can be done in developing countries. With this paper, we would like to suggest the use of mass media in developing countries to increase the maternal education in order to reduce the maternal and neonatal mortality. Although, the cost of using mass media is high, but the effect of using mass media as a media of communication to the society can’t be underestimated, because mass media can reach any kind of society at one time. Therefore, mass media has a high possibility in increasing the Maternal and Neonatal Health.

I.III. Problems Formulation Is there a correlation between maternal education through mass media on maternal and neonatal health factor?

Can mass media be used as a good health education tool? How effective can mass media do as a health education tool?

What is the role of college students in resolving the high maternal and neonatal mortality though mass media?

CHAPTER II

MATERIALS AND METHOD

II.1 Study Design

We use systematic review of cross sectional studies that we had searched from databases such are PubMed, PMC, Clinicalkey, Sciencedirect, according to the inclusion and exclusion criteria we had determined. The keyword we used are “Mass Media” AND “Maternal Health”, and critical analyzed it with CEBMa checklist for cross sectional study. The writing structures are based from combination of PRISMA Guideline and Flowchart and PCC EAMSC Guideline.

Records identified through database searching (n = 278)

Records after duplicates removed (n = 234)

Records excluded (n = 106) Screen for free full text and abstract only (n = 128)

Full-text articles assessed for eligibility

Full-text articles excluded, with reasons

(n = 60)

(n = 68)

Studies included in quantitative synthesis (meta-analysis) (n = 8)

Figure 1. Flowchart of screening procedure based of PRISMA, it shows the number of journal from the beginning to what we used in this research.

II.2 Eligibility Criteria

We included studies from all across the world, which are Indonesia, India, Nepal, and others. For the reason that the data is limited, we lengthened our search year of publication from 2000 to 2017, with the study design must be cross sectional. The Maternal Health factors were defined as birth with skilled attendant, Contraception, exclusive breastfeeding and . The term “Mass Media” was defined as television, internet, newspaper and other reading material, and radio. At the very first screening, we still included full-text article and abstract with English and Indonesian language.

N

Inclusion

Exclusion

o 1

Published from 200X to 20XX

Not significant data with p > 0,05

2

Research method : cross sectional study

Incorrect statistical calculation

3

Relevant to the variable we search

Bias detected

4

Language : English and Indonesia

Figure 2. Inclusion and Exclusion Criteria

II.3 Research Strategy

We search databases such are PubMed, PMC, Clinicalkey, Sciencedirect, etc, according to the inclusion and exclusion criteria we had determined. The keyword we used are “Mass Media” AND “Maternal Health” and according to our optimization test we included all keyword such as ”media access “,”antenatal care”,”exclusive breastfeeding” and “hospital delivery”. The search was limited to cross sectional study and English or Indonesian language.

After we got the data, there were 2 reviewer who critical analyzed, the journals using CEBMa Checklist and discussed the eligibility of the journal until the disagreement resolved.

II.4 Data Analysis

We extracted the data from the journal and created random effect meta-analysis with MedCalc with p <0,05 as the standard. The data that was extracted were title, author, year, period of study, country, type of study, number of positive and negative maternal health results of Mass Media, number of Mass Media exposure, sample size of the study and

summarized with odd ratio ( OR ) and 95% confidence interval (CI) that we re-calculated before. To analyze heterogenity we used Cochran’s Q Test that was provided in MedCalc.

CHAPTER III RESULT

We screened about 278 records and finaly only 9 proceed to full text review.

However, we must exclude 3 of the records because of the bias we have found. We proceed to do 3 meta-analysis according to the factors affecting maternal health according to figure. 1 with 6 last records.

III.1 Mass Media Effect on Exclusive Breastfeeding

Figure 3. Meta-analysis of Mass Media Effect on Exclusive Breastfeeding. All the effect is more than 1.00 with p <0,05 at CI 95% n = 3587.

There are 2 studies that still relevant in the this study, with the total respondent is 3587 from two different places. We used fixed effect meta-analysis because we found that the Q test p value was not significant, thus the data between the records are not different. The overall OR

of exclusive breastfeeding is 2,34 ( 95% CI 1.984 to 2.768, p <0,05 ). This proves that mass media effect has significant positive effect on exlclusive breastfeeding of the neonates.

III.2 Mass Media Effect on ANC Participation

There are 3 studies that was analyzed in this section. With the total respondent 16.235, the P value on the Q test however proves that the data are not similiar. The result could be happened because the differences on sum of the data ( P value <0,05) . As, the data is different, we used random effect meta-analysis to describe the result and found the overall significant odd ratio is 2,78 ( 95% CI 2.076 to 3.718, p <0,001 ). The result proves that mass media effect to mother has 2,78 more likely to participate in Antenatal Care ( ANC ).

Figure 4. Meta-analysis of Mass Media Effect on ANC Participation. All the effect is more than 1.00 with overall odd ratio is 2,78 at p <0,05 at CI 95% n = 16.235.

III.3 Mass Media Effect on Skilled Only 2 studies that was analyzed in this meta-analysis. The total respondent is 6.133 wtih value on the Q test is not significant, means that the data is not different. We used fixed effect meta-analysis and reached the overall significant odd ratio is 3.46 ( 95% CI 2.968 to 4.025, p <0,001 ). The result proves that mass media effect to mother has 3.46 more likely to get help from skilled attendant at the delivery.

CHAPTER 4 DISCUSSION

IV.Discussion

According to Health Development Company (HDA) No.7, the the rapidly growing world’s technology trend has been towards informational technology, especially in mass media.The world today is embarking towards the use of mass media as a political, commercial, and regulatory tool according to each country self-stance. Observing this particular matter, the use of verified mass media on medical aspect could be a breakthrough in increasing the humanity quality of life. One of the applicable example is Possibility to Increase Maternal Education by Mass Media Exposure in Order to Decrease Maternal and Neonatal Mortality.

According to our analysis, it is proven that mass media has a positive effect in increasing maternal education on maternal and neonatal health. Pertaining to this result, further development in application of mass media in medical aspect will give even a more significant positive impact to maternal and neonatal health. Solution such as the extensive use of mass media by govermental and non-govermental institution in increasing maternal education is important. Regulation in a country plays an important role in implementing this solution in a way that goverment could ensure an accurate and effective result. As the awareness of society is increasing towards the development of mass media, it could play an educative and misleading role. The role of mass media as an educative tool is what we are trying to emphasize in advance of the misleading role.

Mass media offer a wide opportunity to reach a large number of people in a short timeframe. Mass media has a huge potential as an awareness-creating tool. It could mediate discussion through emotional or provoking messages. Mass media is also a valuable tool in controling urgent matter or crisis that may arise in medical sector. These trait of mass media, accompanied by regulation and verified by could be potent tool in controling health service.

In addition to maternal, the content of mass media application in medical education aspect could also be targeting faternal side of perspective. Faternal aspect has an important role in sociocultural and family decision making. Equal education, especially especially between maternal and faternal, could increase the effectivity in utilizing Antenatal Care service10.

Especially as a medical student, we could verify the information that was shared by the mass media and try to give a scientific point of view on each information given. Often, we observe some misleading information or unverified medical information exposed to society.

As a medical student, we can also promote the maternal health education to people around us, in order to ensure the exposure of mass media in all society.

There are some limitation in this sytematic review. There is a limited access for a medical student to gather data, as the data available in databases is only available in a small number

V. Conlusion Mass media has significant positive effect on exclusive breastfeeding, skilled healthworker help for delivery, and ANC participation. It shows that mass media holds vast potential for increasing the maternal health through education.

REFERENCES

1.

Acharya D, Khanal V, Singh JK, Adhikari M, Gautam S. Impact of mass media on the utilization of antenatal care services among women of rural community in Nepal. BMC Res Notes [Internet]. BioMed Central; 2015;8(1):345. Available from: http://www.biomedcentral.com/1756-0500/8/345 2.

Bimerew A, Teshome M, Kassa GM. Prevalence of timely breastfeeding initiation and associated factors in Dembecha district, North West Ethiopia: a crosssectional study. International Breastfeeding Journal.

2016;11:28. doi:10.1186/s13006-016-0087-4.

3.

Dhakal S, Lee TH, Nam EW. Exclusive breastfeeding practice and its association among mothers of under 5 children in Kwango district, DR Congo. Int J Environ Res Public Health. 2017;14(5).

4.

Griggs D. From MDGs to SDGs : Key challenges and opportunities.

Harvard Int Rev [Internet].

2015;37(1):58–61.

Available from: https://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=112592255&site = ehostlive%5Cnhttps://sustainabledevelopment.un.org/content/documents/3490griggs.pdf 5.

Health Development Agency. The effectiveness of public health campaigns.

Consum Mark. 2004;(7):1–5.

6. p.

Kementerian Kesehatan RI. Profil Kesehatan Indonesia 2015. 2016. 403

7.

Nguyen, TT; Alayón, S; Jimerson, A; Naugle, D; Nguyen, PH; Hajeebhoy, N; Baker, J; Baume , C; Frongillo E. No Title. Am J Public Health [Internet].

2017;107(3):312–218.

Available

from:

https://www.ncbi.nlm.nih.gov/pubmed/279972 34 8.

Shahram MS, Hamajima N, Reyer JA. Factors affecting maternal healthcare utilization in Afghanistan: secondary analysis of Afghanistan Health Survey 2012.

Nagoya J Med Sci [Internet]. 2015;77(4):595–607. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4664591&tool=pmcentr ez

&rendertype=abstr act 9.

Tsegay R, Aregay A, Kidanu K, Alemayehu M, Yohannes G. Determinant factors of home delivery among women in Northern Ethiopia: a case control study.

BMC Public Health [Internet]. BMC Public Health; 2017;17(1):289. Available from: http://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-41591%0Ahttp://www.ncbi.nlm.nih.gov/pubmed/28372540%0Ahttp://www.pubmedcent ra l.nih.gov/articlerender.fcgi?artid=PMC5379537 10.

White D, Dynes M, Rubardt M, Sissoko K, White BD, Dynes M, et al.

The Influence of Intrafamilial Power on Maternal Health Care in Mali : Perspectives of Women , Men And Mothers-in-Law Linked references are available on JSTOR for this article : The Influence of Intrafamilial Power on Maternal Health Care in Mali : Perspe. 2016;39(2):57–68.

11.

Zamawe COF, Banda M, Dube AN. The impact of a community driven mass media campaign on the utilisation of maternal health care services in rural Malawi. BMC Pregnancy Childbirth [Internet]. BMC Pregnancy and Childbirth; 2016;16(1):21. Available from: http://www.biomedcentral.com/14712393/16/21 12.

Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Open Med 2009; 3(3); 123-130 13.

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14.

MedCalc Statistical Software version 16.4.3 (MedCalc Software bvba, Ostend, Belgium; https://www.medcalc.org; 2016)"

The Overview of Caesarian Section Indication in Makassar as an Outlook of Fetomaternal Health in Indonesia Ilham Akbar Rahman1, Iin Fadhilah Utami1, FadhilahPutri Wulandari1 , Zakirunallah Karunia1 1

Faculty of Medicine Hasanuddin University (AMSA-Unhas)

Introduction In Indonesia, the birth rate is still high and abnormal labor, which requires special manipulation during labor, constitutes 15% of all deliveries. Cesarean section is the solution for such complicated cases. Doctors are still confused with various problems in adapting cesarean section because of increased morbidity and mortality in mothers and in newborn babies. In this case, cesarean section is done not as a primary indication rather as a secondary indication for operation.4 Consequently antenatal check up of pregnant mother is very essential to maintain good maternity services. Surgical intervention could decrease the mortality and morbidity rates of newborn babies in complicated cases. The mortality and morbidity rate of mothers and infants in Indonesia is still high. Caesarean section is a surgical procedure through mother’s abdomen and uterus to deliver the baby.Cesarean section is done as a secondary indication for some complicated cases. Only 25% of all hospital delivers in Indonesia undergoing this surgical intervention.

The aim of the study was to find the correlation of caesarian section indications and conditions of maternal and the newborn. In the end we hope our research can provide a better outlook on Fetomaternal health in Indonesia as a way to influence the government to evaluate several factors that contribute in decreasing the mortality and morbidity of maternal and child as the way to improve fetomaternal health quality in Indonesia.

Material and Methods A cross-sectional study was` conducted among all mothers and infants at one of the main referred delivers hospital inMakassar (Fatimah maternity hospital) from January 1st to June 30th2016. During that period, we collected and evaluated data from the patients whocame and conducted Caesarian section with any indicationsin Emergency department, outpatient and inpatient department. Samples were collected and analyzed using SPSS. The inclusion criteria for the samples is woman who conducts cesarean section with any indication and no exclusion criteria for the samples.

The definition of each variables are: -

Sectio cesarean indication is variables that include any disease or condition as being the indication of the patients to conduct their cesarean section.

-

Newborn condition is variables that assessed by APGAR score that is divided in to 3 groups namely: normal (scored 7-10), moderate asphyxia (scored 4-6) and severe asphyxia (scored 0-3)

-

Patient’s refer is variables that contains where the Fatimah’s hospital patients come from

-

Levels of patient’s education is variable that contain when was the latest education had

- Newborn weight is variable that contains the weight of newborn neonates that is divided in to three groups namely: <2500, 2500-4000, >4000.

Results:

In this study, 119 babies were evaluated from mothers who underwent caesarian section.

Table 1. The Sectio Cesarean Indications

Sectio Cesarean Indication 35

30

30 25 20

20

19

15 10 5

8

8

9

9 6 4

0

Diagram 1. Section Cesarean Indication

5

SC history Malpresentation Induction failure Fetal distress Severe Preeclampsia Narrow Pelvis Gemelli Late vaginal delivery

Plasenta Previa

Others

Sectio Cesarean Indication

Indications of section caesarian as seen in table 1 and diagram 1 were 30 (25,4%) with CS history, 19 (16,1%) due to malpresentation, 9 (7,6%) due to severe preeclampsia and narrow pelvic, 8 (6,8%) due to induction failure and fetal distress, also 6 (5.1%) 4 (3.4%) 5 (4.2%) due to gemelli, late vaginal delivery and placenta previa respectively.

Table 2. Correlation of Newborn condition and patient’s refer (SIGNIFICANT)

General

Puskesmas

Physician’s

Puskesmas

Maternity

General

clinic

Pembantu

hospital

Hospital

Practicioner

Total

Chi Square

Severe Asphyxia

0

7

0

0

3

0

10

Moderate

0

8

2

0

0

4

14

Normal

1

66

13

2

4

9

95

Total

1

81

15

2

7

13

119

Asphyxia

0,042

As seen in Table 2, patients are referred from GP 1 (0.8%), Puskesmas 81 (68.1%), Clinic 15 (12.6%), Puskesmas pembantu 2 (1.7%), Maternity hospital 7 (5.9%) and General hospital 13 (10.9%). There were a significant difference between newborn condition and patient’s refer (p<0.05).

Table 3. Correlation of Newborn condition and Level of patient’s education (SIGNIFICANT)

Level of Education

Newborn Condition

Severe asphyxia

Total

D3

S1

SD

SMA

SMK

SMP

0

0

3

5

0

2

10

Chisquare

Total

Moderate asphyxia

0

5

4

4

1

0

14

Normal

7

6

25

35

2

20

95

7

11

32

44

3

22

119 0,035

Table 3 shows the level of mother’s education were D3 7 (5.9%), S1 11 (9.2%), SD 32 (26.9%), SMA 44 (37.0%), SMK 3 (2.5%) and SMP 22 (18.5%). There was significant difference in newborn condition and level of patient’s education (p<0.05)

Table 4. Correlation of Newborn condition and Newborn weight (SIGNIFICANT)

Newborn weight

Newborn condition

Total

Kruskall-

<2500

2500-4000

Total

Severe asphyxia

5

5

10

Moderate asphyxia

5

9

14

Normal

16

79

95

26

93

119

Wallis

0,018

Table 4 shows the level of newborn weight were classified as <2500 g 26 (21.8%) and normal weight (2500 g-4000 g) 93 (78.2%). There were significant difference between the level of newborn condition and newborn weight p<0.05).

Table 5. Correlation of newborn condition and SC indication (NOT SIGNIFICANT)

SC Indication

Total

ChiSqua re

Fetal Condition

Late

Plasenta

Previous SC History

Malpresenta tion

Induction failure

Fetal distress

PE B

Narrow Pelvis

Gemelli

vaginal delivery

Previa

IUFD

3

0

1

2

0

0

1

0

0

3

10

3

2

2

0

2

0

1

2

0

2

15

24

17

5

6

7

9

4

2

5

15

94

30

19

8

8

9

9

6

4

5

20

119

Severe asphyxia Moderate asphyxia Normal

Total

Table 5. shows the newborn condition based on APGAR score, severe asphyxia 10(8.4%), 15 (12.6%), 94 (79.0%). No significant relationship (p>0.05) existed between the newborn condition and indication of cesarian section.

0,340

Discussion: This study provided caesarian section indication in all mothers and infants at one of the main referred delivers hospital inMakassar (Fatimah maternity hospital).The first highest percentage indication of Caesarian sections is there was patient's previous history of SC. Previous history of SC is a relative indication for section cesarean where Ioannis et al in the research of indications for and risk of elective cesarean section conclude that with vaginal birth after previous cesarean delivery, there is a risk of rare but serious adverse outcomes (increased rate of perinatal deaths and hypoxic brain damage), whereas with repeat cesarean the risks are more frequent but less serious (eg incrased rate of children impaired respiratory adaptation).2

In this study, majority attending the hospital were from Puskesmas (primary health care) was 68,1%. This is in line with study conducted by Gurung et al in Nepal also found the majority attending were from rural hilly regions of Nepal. Moreover, those who came from puskesmas, 7 (5.8%) of them as the most number had severe asphyxia and 8 (6.7%) of them as the most number had moderate asphyxia . As the result is significant (p<0.05) proves that labour management and newborn management quality in our peripheral health providers like puskesmas and others need to be increased as we advance towards better fetomaternal health. This data also show us that the role of primary health care as the first line facility in early detection and treatment is crucial because most of the patient’s refer were come from Puskesmas as the primary health care.

We also found the significant correlation of newborn condition and level of patient’s education. Gurung et al found the higher education and grand multiparity were the most influencing factor of CS. The significance may shows that such awareness and antenatal care during pregnancy are important factor of good newborn condition. This is according to EBCOG Scientific committee on it’s research of The Public Health Importance of Antenatal Care as said that the initial phases of pregnancy have a large impact on perinatal and subsequent adult health, optimal care needs to be initiated before pregnancy.

Our result found that from patients who undergo Cesarean section, 21% of them (25 from 119) had asphyxia but there is no significant relationship of the newborn condition and caesarian section indication. Our data prove that the cesarean section procedure does not highly interfere the condition of the newborn, therefore we still highly supported the use of cesarean section in such complicated cases that is indicated.Meanwhile in the research of Tjiptaet al found that asphyxia in babies born after CS was relatively high and related with the fetal and maternal status3.

Conclusions:The newborn condition of Caesarian section was highly correlated with level of mother’s education, newborn weight, and mothers’s refer. Therefore, by this data we can show to the government as those contributing factors should be evaluated to improve the facilitation to decrease the mortality and morbidity of maternal and child as the way to improve fetomaternal health quality in Indonesia.

References: 1. Gurung, R., Gurung, G., Shrestha, R., Gurung, T., & Sharma, P. (2017). Prevalence and Outcome of Cesarean Section at Gandaki Medical College Teaching Hospital and Research Centre, Pokhara, Nepal. Journal Of Gandaki Medical College-Nepal, 9(2), 16.doi:http://dx.doi.org/10.3126/jgmcn.v9i2.17858

2. AZAMI-AGHDASH, S., GHOJAZADEH, M., DEHDILANI, N., MOHAMMADI, M., & ASL AMIN ABAD, R. (2014). Prevalence and Causes of Cesarean Section in Iran: Systematic Review and Meta-Analysis. Iranian Journal of Public Health, 43(5), 545–555.

3. Busarira, M., Gahwagi, M., &Alaguria, N. (2016). Rate, Indications and Complications of Caesarean Section at Aljamahiriya Hospital, Benghazi, Libya.Journal of High Institute of Public Health, 41(3), 359-367. Retrieved from http://jhiph.alexu.edu.eg/index.php/jhiph/article/view/257

4. Guslihan D Tjipta, Riza I Nasution, Dachrul Aldy, Zakaria Siregar (2003). Pattern of newborn babies delivered by cesarean section.

Pediatrica Indonesiana Volume 43.

THE CORRELATION BETWEEN PARITY AND CERVICAL CANCER AMONG PATIENT IN DR. SAIFUL ANWAR HOSPITAL MALANG Meilia Zainudin1, Putu Ijiya Danta Awatara2, Reselina Utami3, Yogesvara4 University of Brawijaya

Background: Cancer may occur in female reproductive organs, such as breasts, cervix, ovaries, and vagina. In Indonesia, there are over 15.000 cases of cervical cancer, with around 8.000 deaths occur annually. In 2006, Anatomy Pathology Association of Indonesia reported that mortality rates due to cervical cancer in Indonesia is very high because most of the patients came with cervical cancer at an advanced stage or terminal stage. Human papilloma virus (HPV) is the main cause of cervical cancer. Cervical cancer may also caused by other risk factors such as health and sexual factors, socioeconomic factors, low economic rates, ethnic minorities, and other factors including tobacco exposure, lack of appropriate screening, and treatment of previous intraepithelial cervical neoplasia (Rasjidi, 2009). Based on key studies on cervical cancer, Women with parity ≥3 had 4.375 times higher odds of having cervical cancer compared to those in the lower parity (<3). It can be concluded that high parity is one of the cervical cancer risk factor.

Aims and objectives: to investigate the correlation between parity and occurrence of cervical cancer.

Methods: This is an observational analytic study with case control design using secondary data of cervical cancer cases and controls that meet the inclusion criteria. It was conducted in Dr. Saiful Anwar Hospital, Malang in 2012-2014. Data will be processed using SPSS application with spearman and chi square correlation statistic analysis with 95% confidence level and α 0,05.

Results: Based on Spearman study, there is a weak correlation between parity and cervical cancer (R=0,246). Chi-Square test showed a significant relationship between the number of parity with cervical cancer (p =0.015 and χ2 = 5,939, and the value of χ2 tables with degrees of freedom = 1, and the error rate of 5% is 3.841, χ2 = 5,939 is bigger than value χ2 table = 3,841 or p value = 0,015 <5% (α = 5%).

Conclusion: There is a significant relationship between parity as one of the risk factors of cervical cancer. The incidence of cervical cancer are higher in samples with the number of partial ≥3 as evidenced in the study that women with parity ≥3 had a risk of cervical cancer ± 3X compared with women with parity <3 with the largest proportion is women with the number of parity 3. Parity is one of the risk factor of cervical cancer but not the main cause.

Keyword: Parity, Cervical Cancer, Risk Factor Author : 1

Meilia Zainudin 089693239707 meiliazainudin@gmail.com

2

Putu Ijiya Danta Awatara 081232270119 ijiyadanta19@gmail.com

3

Reselina Utami 082233697502 reselina_utami@yahoo.com

4

Yogesvara

085755139596 yogesvara26@gmail.com Regional Chairperson of AMSA Indonesia : Elvira Lesmana +6285811240637 rcindonesia@amsa-international.org

THE CORRELATION BETWEEN PARITY AND CERVICAL CANCER AMONG PATIENT IN DR. SAIFUL ANWAR HOSPITAL MALANG

by:

Meilia Zainudin

batch 2012

Putu Ijiya Danta Awatara

batch 2014

Reselina Utami

batch 2016

Yogesvara

batch 2016

FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY MALANG 2017

1. INTRODUCTION

Cancer is a disease caused by an abnormal physical condition and unhealthy lifestyle. Cancer may occur in female reproductive organs, such as breasts, cervix, ovaries, and vagina1 Worldwide, Cervical cancer is the second most common cancer, with the number of cases reached 471.000 and accounting for nearly 123.000 deaths2. In 2006, Anatomy Pathology Association of Indonesia reported that mortality rates due to cervical cancer in Indonesia is very high because most of the patients came with cervical cancer at an advanced stage or terminal stage 3.

Human papilloma virus (HPV) is the main cause of cervical cancer. Cervical cancer may also caused by other risk factors such as health and sexual factors, socio-economic factors, low economic rates, ethnic minorities, and other factors including tobacco exposure, lack of appropriate screening, and treatment of previous intraepithelial cervical neoplasia4.

Several factors are thought to increase the incidence of cervical cancer, namely parity, lack of genital hygiene, chronic trauma to the cervix, and oral contraceptive use in long term that is more than 4 years5.

According to Surbakti (2004), parity has a significant relationship with the occurrence of cervical cancer. Women with parity ≥3 had 4.375 times higher odds of having cervical cancer compared to those in the lower parity (<3). It can be caused by cervical trauma in vaginal delivery that cause an inflammation and subsequently turn into cancer, and also hormonal change and immunosuppression condition in pregnancy make the cervix more vulnerable to HPV exposure.

This study aims to investigate the correlation between parity and occurrence of cervical cancer in General Hospital of Dr. Saiful Anwar Malang Period 2012-2014 ".

2. MATERIAL AND METHODS This research is an analytic observational method using case control design, a case report that provides an overview or profile of cervical cancer patients in General Hospital of Dr. Saiful Anwar Malang from Januari 2012 to December 2014 and an analysis the relationship between parity and occurrence of cervical cancer in General Hospital of Dr. Saiful Anwar Malang from Januari 2012 to December 2014.

The population of this research were all patients of SMF Obstetrics and Gynecology at General Hospital of Dr. Saiful Anwar Malang from Januari 2012 to December 2014.

The sample of this study is part of the population that fulfill the inclusion and exclusion criteria. The sample size is calculated by a large sample formula for unpaired categorical analytic research (Dahlan, 2005)

The unpaired categorical analytic research :

[zα √2pq + zβ √(p1q1 + p2q2)] 2

n

=

( p1 – p2 )2

n

= the size of each group sample

Zα

= the average deviation value of a standard normal distribution bounded by α ≈

1.96 = the average deviation value of a alternative distribution bounded by β ≈ 0.84

Zβ

the number of cervical cancer patients that fulfill the inclusion exclusion criteria

p11

the total number of cervical cancer and non – malignant patients that fulfill the inclusion exclusion criteria

=

289 =

= 0,4676 618

q1

= 1 - p1

= 1 – 0,4676

= 0,5323

p2

= the proportion of parity in non-malignant patients that fulfill the inclusion exclusion criteria ≈ 0,5

q2

= 1 - p2

= 1 - 0,5

= 0,5

p1 + p2 p

=

0,4676 + 0,5 =

2

q

=

0,4838

2

=1–p

= 1 - 0,4838

= 0,5162

Thus, the sample size obtained for each group :

n = [1,96 √2 x 0,4838 x 0,5162 + 0,84 √(0,4676 x 0,5323 + 0,5 x 0,5)]2

(0,2)2

n = (1,96 √0,4994 + 0,84 √0,4989)2

0,04

n = (1,3851 + 0,5933)2

0,04

n = 3,914 = 97,85 ≈ 98

0,04

Thus, the total number of cervical cancer and non-malignant patients required for this research at least 98 people divided into 49 cervical cancer patients and 49 nonmalignant patients.

Sample Inclusion Criteria:

- All patients with cervical cancer

- Examined at General Hospital of Dr.Saiful Anwar Malang

- The period from January 2012 to December 2014

- Has no history of oral contraceptives

- Socio-economic middle to top

Inclusion Control Criteria:

- All non-malignant patients in SMF Obstetrics and Gynecology

- Examined at General Hospital of Dr.Saiful Anwar Malang

- The period from January 2012 to December 2014

- Has no history of oral contraceptives

- Socio-economic middle to top

Exclusion Criteria:

- Patients with cervical cancer and accompanied by other cancers

- Examined outside General Hospital of Dr.Saiful Anwar Malang

- The period before January 2012 and after December 2014

- Have a history of oral contraceptives

- Low socio-economic

Based on the purpose of the research, then the variables studied is the variable number of parity and variable of cervical cancer patients in General Hopital of Dr. Saiful Anwar Malang from Januari 2012 to December 2014

Independent variable : Number of parity

Dependent variable : Cervical cancers

Control variable : Non-malignant

Materials and research instruments used are medical records of cervical cancer patients and non-malignant patients of SMF Obstetrics and Gynecology at General Hospital of Dr. Saiful Anwar Malang from Januari 2012 to December 2014 Calculation the number of samples using statistical formula

Collection of files (medical records) according to inclusion and exclusion criteria

Data recording: Name Age Address Work Weight Height Class treatment Final diagnosis Parity data

Data analysis Analyze the results

Data will be processed using SPSS application with spearman and chi square correlation statistic analysis with 95% confidence level and α 0,05.

3. RESULTS Based on the results of data processing, it can be described characteristics of cervical cancer patients in General Hospital of Dr.Saiful Anwar Malang Period 2012-2014

Table 1.1 Patient Age

Age

Frequency

Percentage (%)

≤30 years old

0

0

31 - 40 years old

10

20.4

41 - 50 years old

16

32.7

> 50 years old

23

46.9

Total

49

100

Table 1.1 shows that patients aged between less than or equal to 30 years old are 0 people or 0 %, patients aged between 31-40 years old are 10 people or 20,4%, patients aged between 41-50 years old are 16 people or 32,7%, and patients over he age of 50 years old are 23 people or 46,9%

Then, the data processing comparison the number of parity with the incidence of cervical cancer is attached in the following table:

Spearman’s rho Jenis Kanker

Jenis kanker 1.000

Paritas .246*

Sig. (2-tailed)

.

Correlation Coefficient

N Paritas

Table 1.2 Relationship Between

98

Correlation Coefficient

.246*

Sig. (2-tailed)

.015

The Number of Parity and

Cervical Cancer

Correlations

Source : secondary data

Table 1.2 shows a correlation coefficient of 0.246 that the relationship between parity and cervical cancer is categorized as weak and positive because it is at the interval of 0.2 to 0.4. If the parity is more than or equal to 3, then the higher rates of cervical cancer patients

The results of analysis using Chi Square test (2) :

The cross-tabulation that can describe the dissemination of detailed data between the number of parity and cervical cancer patients can be seen in Table 1.3

Tabel 1.3 Cross-tabulation between the number of parity and type of cancer

Parity * type of cancer Cross-tabulation

Type of cancer

Parity <3

Non

Cervical

Malignant

Cancer

33

21

54

% of Total

33.7%

21.4%

55.1%

Count

16

28

44

% of Total Count

16.3% 49

28.6% 49

44.9% 98

% of Total

50.0%

50.0%

100.0%

Count

≥3 Total

Total

Table 1.3 shows that from 98 people are divided into four groups. Cervical cancer patients with parity <3 are 21 people or 21.4% and patients with parity ≥ 3 are 28 people or 28.6%. Non-malignant patients with parity < 3 are 33 people or 33.7% and patients with ≥ 3 are 16 people or 16.3 %.

The associaton between the number of parity and cervical cancer patients can be seen on the Chi Square test below.

Table 1.4 Chi Square Test

Value

df

Asymp. Sig. (2sided)

Pearson Chi-Square

5.939

1

.015

Table 1.4 shows that the result of Chi Square test with p value is 0.015 and χ2 = 5,939, and the value of χ2 tables with degrees of freedom = 1, and the error rate of 5% is 3.841, , then the value of χ2 = 5,939 is bigger than value χ2 table = 3,841 or p value = 0,015 <5% (α = 5%), so it can be concluded that there is a significant relationship between the number of parity with cervical cancer. The results of the analysis also obtained Odds ratio at 0,364 which means that patients with parity more than or equal to 3 increases the risk of cervical cancer 3 times greater than patients with parity less than 3.

4. DISCUSSION According to the results of research from medical record data of patients in General Hospital of Dr. Saiful Anwar Malang Period 2012 – 2014 can be seen that patients aged between less than or equal to 30 years old are 0 people or 0 %, patients aged between 3140 years old are 10 people or 20,4%, patients aged between 41-50 years old are 16 people or 32,7%, and patients over the age of 50 years old are 23 people or 46,9%. Patients over the age of 40 years old are the most common risk factors in the incidence of precancerous lessions and cervical cancer and it has been proved in many studies6. Belinson’s statements is supported by several studies. Melva (2008) in his research found that the most common cervical cancer patients are in the age group ≥40 years old with the percentage at 76,6 %. In this study, no cases of cervical cancer were found in the age group <20 years old.

This may be occur due to the lower number of parity in the age group <20 years old and other low risk factors, such as never having sexual intercourse.

Zai (2009) in his research about Individual Characteristic of Cervical Cancer Patients in General Hospital of H. Adam Malik Medan period 2003 – 2007 shows that the most common cervical cancer patients are in the age group >40 years old with the percentage at 76,8% from 492 cases studied.

The most common cervical cancer patients are in the age group >40 years old occurs because it takes a long time in the epithelial cell displacement and invasive carsinoma. The dysplasia changes into an insitu carcinoma takes about 1-7 years whereas insitu carcinoma changes into invasive carsinoma takes about 3-20 years (Tambunan,1995). Preinvasive period (growth of abnormal cells before turns into malignant) of cervical cancer is quite long. In the early stage of infection before becoming cancer is preceded by a precancerous lession called Cervical Intraepithelial Neoplasia (CIN) or Neoplasia Intraepitel Serviks(NIS). Precancerous lession takes about 10-20 years. CIN I (NIS I) will develop into CIN II (NIS II) and then become CIN III (NIS III). If the disease continues, it will develop into cervical cancer7

The results of analysis using Chi Square test (2) : Table 1.3 shows that from 98 people are divided into four groups. Cervical cancer patients with parity <3 are 21 people or 21.4% and patients with parity ≥ 3 are 28 people or 28.6%. Non-malignant patients with parity < 3 are 33 people or 33.7% and patients with ≥ 3 are 16 people or 16.3 %. The results are in line with research by Nasution (2010) who found that 58.5% of cervical cancer patients are multiparous.

Irianti (2003) in her research found that the most common cervical cancer patients are having parity >3 times with the percentage at 82.1%, whereas according to Aida’s research (2010) the most frequent parity are ≥6 times with the percentage at 58.7%. in this study, however, it is rare to find the number of parity ≥6 times due to the habitual changes of having many children in ancient times compared to modern era.

The result of Chi Square test with p value is 0.015 and χ2 = 5,939, and the value of χ2 tables with degrees of freedom = 1, and the error rate of 5% is 3.841, , then the value of χ2 = 5,939 is bigger than value χ2 table = 3,841 or p value = 0,015 <5% (α = 5%), so it can be concluded that there is a significant relationship between the number of parity with cervical cancer. The results of the analysis also obtained Odds ratio at 0,364 which means

that patients with parity more than or equal to 3 increases the risk of cervical cancer 3 times greater than patients with parity less than 3.

The results are in line with research by Surbakti E (2004) that shows women with parity ≥3 have 4.375 times greater risk of cervical cancer . according to the results of the IARC (2002), nulipara women (parity 1-2) had a cervical cancer risk at 1.8 times, while women with parity 3-6 had a cervical cancer risk at 2.6 to 2.8, and women with parity ≥7 had a cervical cancer risk at 3.8 times.

The IARC study shows an increased number of parity is directly proportional to the increased risk of cervical cancer, this is related to the theory of cervical cancer in general, ie cervical cancer is the most prevalent in women who often give birth.

Hormonal changes that occur during pregnancy and cervical trauma that occur during childbirth are thought to be factors that causes cervical cancer 8. In addition, there are other factors causing cervical cancer associated with pregnancy and parity. Pregnancy is associated with the occurrence of immunosuppression that allows the process of malignancy and replication of HPV9. According to Manuaba (2002), an increased incidence of infection is greater in pregnancy and childbirth ≥3 times, estimated risk of cervical cancer is 3-5 times greater in women who are often give childbirth. According to Harahap (1997), high pervaginam childbirth causes the number of cervical cancer increases due to the frequency of a woman giving birth, it willl affect the frequent occurrence of injuries in the reproductive organs in which the wound will facilitate the emergence of HPV as a cause of cervical cancer

5. CONCLUSION There is a significant relationship between parity as one of the risk factors of cervical cancer. The incidence of cervical cancer are higher in samples with the number of partial ≥3 as evidenced in the study that women with parity ≥3 had a risk of cervical cancer ± 3X compared with women with parity <3 with the largest proportion is women with the number of parity 3. In addition, population of cervical cancer patients most found in the age group more than 50 years.

We are expecting that there will be further research regarding this study that discuss other cervical cancer risk factors with different variables and methods for educational progress as well as decreased incidence rates of cervical cancer.

To the government and other related institutions are expected to increase the extension efforts to the community about the benefit of Keluarga Berencana (KB) program as one of the strategies for women in reproductive age in limiting the number of pregnancies and childbirths,namely 2 children are enough to reduce the risk of cervical cancer.

6. REFERENCES 1. Mangan,Y. 2003. Cara Bijak Menaklukkan Kanker. Jakarta: Agromedia Pustaka 2.

Alejandro mohat, M. F. 2000. Epidemiology of cervical cancer. cancer investigation, p. 584-590.Alliance for Cervical Cancer Prevention, 2004. Risk Factors for Cervical Cancer: Evidence http://screening.iarc.fr/doc/RH_fs_risk_factors.pdf.

to

Date,

USA.

3. Depkes RI. (2009). Buku Saku Pencegahan Kanker Leher Rahim dan Kanker Payudara. Jakarta: Ditjen PP & PL. 4. Aida. 2010. Karakteristik Penderita Kanker Serviks yang Dirawat Inap di RSUP. H. Adam Malik Medan tahun 2009. Tugas Akhir. Tidak diterbitkan, Fakultas Kedokteran Universitas Sumatra Utara, Medan.

5. Diananda R. 2007. Mengenal Seluk Beluk Kanker. Yogyakarta : Katahati.

6. Arifuddin, Djuanna. 2000. Penanganan Neoplasma Intraepitel Serviks, Buku Kedokteran EGC, Jakarta.

7.

Belinson S.,Smith J.S.,Myers E.,Olshan A.,Hartmann K., 2002, Descriptive Evidence That Risk Profiles for Cervical Intraepithelial Neoplasia 1,2 & 3 are Unique,Am.J, p. 189:295-304.

8. Dahlan, Sopiyudin. 2005. Besar Sampel dalam Penelitian Kedokteran Kesehatan Arkans, Jakarta, hal. 42-46.

9. Harahap, Rustam E. 1984. Neoplasia Intraepitel pada Serviks, UI-PRESS, Jakarta.

10. Hoyo, C., Yarnall, K., & Fortney, J., 2007. Short Birth Intervals and Uterine Cervical Cancer Risk in Jamaican Women, North Carolina: NIH Public Acces.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2074891/pdf/nihms26881. pdf.

11. International

Agency

for

Research

on

Cancer

(IARC),

2002.

Oral

Contraceptives, Parity, and Cervical Cancer, USA: Alliance for Cervical Cancer Prevention.http://www.thelancet.com/journals/lancet/article/PIIS01406736%2802 %29 08125-4/fulltext#bib10

12. Irianti, E., 2003. Karakteristik Penderita Kanker Serviks Uteri Rawat Inap Di Rumah Sakit Umum Pusat Haji Adam Malik Medan Tahun 1998 – 2002. Tugas Akhir. Tidak diterbitkan, Fakultas Kedokteran Universitas Sumatra Utara, Medan.

13. Manuaba. 2002. Kapita Selekta Penatalaksanaan Rutin Obstetri Ginekologi/KB, 1st ed., Buku Kedokteran EGC, Jakarta.

14. Melva. 2008. Faktor-faktor yang Mempengaruhi Kejadian Kanker Leher Rahim Pada Penderita yang Datang Berobat di RSUP. H. Adam Malik Medan Tahun 2008. Tesis. Tidak diterbitkan, Fakultas Kedokteran Universitas Sumatra Utara, Medan.

15. Nasution, P. S. 2010. Karakteristik Penderita Kanker Serviks yang Dirawat Inap di RSU dr. Pirngadi Medan. Tugas Akhir. Tidak diterbitkan, Fakultas Kedokteran Universitas Sumatera Utara, Medan.

16. Surbakti, E. 2004. Pendekatan Faktor Risiko Sebagai Rancangan Alternatif dalam Penanggulangan Kanker Serviks Uteri di RSU Pirngadi Medan. Tesis.

Tidak diterbitkan, Fakultas Kedokteran Universitas Sumatera Utara, Medan.

17. Tambunan, G. W., 1996. Diagnosis dan Tatalaksana Sepuluh Jenis Kanker Terbanyak di Indonesia, Penerbit Buku Kedokteran EGC, Jakarta.

18. Zai, Alfian Elwin. 2009. Karakteristik Penderita Kanker leher Rahim Yang Dirawat Inap Di Rumah Sakit Umum Pusat Haji Adam Malik Medan. Medan: Universitas Sumatera Utara. http://repository.usu.ac.id/handle/123456S

MP-RELAXIN (Maternal Portable Relaxation Machine): Non pharmacological pregnancy pain innovation based on vibration, temperature and aromatherapy Mokhamad Fahmi Rizki S1, Dedy Budi Kurniawan1, Fakhia Iffatunnisa1, University Of Brawijaya

Abstract Pregnancy is a natural process for every woman. There are several things that cause discomfort such as Pregnancy-related Low Back Pain or Pelvic Gridle Pain. This pain can have a negative effect on the life of the mother because the mother will be bothered to perform daily activity. To reduce pain during pregnancy and childbirth, many therapies have been developed, both pharmacologically and non-pharmacologically. However, most of the pharmacological therapies have negative side effect for pregnant women and its fetus. The innovation of non-pharmacological therapy tools we propose can be a safe, easy to use, and inexpensive pregnancy pain reliever. This tool is expected to help relieving pain in pregnancy, so that pregnant women do not feel disturbed and can remain active. It uses vibrationbased technology, thermal temperatures, and aromatherapy combined into a set of device. The main components used in this tool are microcontroller¸ temperature sensor (DHT 11) which act as a heat controller, vibrator, and aromatic sprayer. The heat can be adjusted until the pregnant women is not bothered by the pain again. Frequency of vibration to produce relaxation effect can also be arranged according to individual body capability. Aromatic sprayer is active based on timer work. Every 5 minutes, the timer will trigger the microcontroller to command sprayer spray aromatherapy. This device is used in the medial part of the back of pregnant women. Frequency of vibration, aromatherapy, and hot temperatures can be adjusted by the user. In testing the effectiveness of the tool, Numeric Rating Scale (NRS) is used to calculate the degree of pain based on the questionnaire given before and after the use of the tool. In addition, the observation of pain is obtained by looking at the expression

of pregnant women. Target market MP-Relaxin is pregnant and maternal women who need quick treatment to overcome the pain of pregnancy and childbirth. Our current focus is product refinement, patent acquisition, and mass production. We will collaborate with IMERI, IBI, IDI, POGI, puskesmas, hospitals, posyandu, and even Kemenkes for socialization based on community. We use long term customer relationship method by connecting network user platform.

Keywords: Pregnancy pain, labor pain, non-pharmacological therapy, vibrator, temperature sensor, aromatic sprayer, Numeric Rating Scale (NRS).

MP-RELAXIN (Maternal Portable Relaxation Machine): Non Pharmacological Pregnancy Pain Innovation based on Vibration, Temperature and Aromatherapy

by:

Mokhamad Fahmi Rizki S.

batch 2015

Dedi Budi Kurniawan

batch 2015

Fakhia Iffa Tunnisa

batch 2015

FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY MALANG 2017

1. BACKGROUND Pregnancy is a natural process for every woman. When undergoing this process the body undergoes changes either physically or emotionally. This change occurs as a form of body adaptation.

Not all of these changes can be well received by the body. There are several things that cause discomfort such as Pregnancy-related Low Back Pain or Pelvic Gridle Pain. This may be due to a change in the size of the uterus resulting in lumbar lordosis. In otherwise, weight gain and weak ligaments can increase the gravitational and mechanical load on Supportive Lumbar Discs1.

Several studies have shown that in primitive societies, their labor is longer and painful; while people in this decade 7-14% have painless maternal and (90%) have labor and pain. Pain is a problem that naturally occurs in pregnant women in labor2. Approximately 45% of pregnant women experience pain and 25% of women after delivery also feel Pregnancy-related Low Back Pain (PLBP) or Pelvic Gridle Pain (PGP)3. Pain during pregnancy can have a negative effect on the mother's life because the mother will be difficult to perform daily activities normally4.

To reduce pain during pregnancy and childbirth, many therapies have been developed by pregnant women, both pharmacologically and non-pharmacologically. Commonly used pharmacological therapy is Acetaminophem which is used as the main choice. Acetaminophem has an effect similar to that of NSAID analgesics with no antiprostaglandin or platelet inhibitory effect 5.

Unfortunately, pharmacological therapy is more expensive and often causes side effects

2. METHODS The preparation of this program is based on an applicative problem, the planning and The preparation of this program is based on an applicative problem, the planning and realization of the system in order to work consistently with the aim and based on the background and formulation of the problem. The steps that need to be done to realize the system to be made are as follows.

2.1 Literature Studies The literature study contains a series of search and review activities of relevant and reliable sources related to non-pharmacological treatment of pregnancy-related pain and tech-based delivery.

Used literatures come from textbooks and scientific journals on pregnancy, childbirth, etiology and pathophysiology, and pain therapy.

2.2 Search Tools Components The search of the components of the tool used to create MP-RELAXIN is obtained from several electronics stores located in Malang, Surabaya and several online stores. The making process of this tool consists of several supporting components and four main components, which are: Arduino

Microcontroller kit as an automatic control tool, vibrator as a source of vibration relaxation, heater to provide heat to the user's body and sprayer to provide aromatherapy.

3. RESULTS AND DISCUSSION 3.1 Tool Design

In general, the tool that will be made consists of several blocks such as voltage source, temperature sensor, button, microcontroller, LCD, heater, vibrator and sprayer (Figure 1).

Temperature Sensor

Voltage Source

Button

Microcontroller Heater

LCD

Vibrator

Sprayer

Figure 1. Block Chart of MP-RELAXIN

The working system of MP-RELAXIN: 1. Voltage source is coming from chargeable15 Volt battery DC with 300 Watt power connected by MP-RELAXIN into microcontroller. Next, this voltage will be the source for the existing components such as sensors, buttons, vibrators, LCD, heater and sprayer.

2. The button functions as an on / off switch and adjustion of temperature level, then connected to the microcontroller. When the on / off button is pressed, the red indicator light will light up. After that, the user presses the button to set the choosen temperature as stated on the LCD. Then the heating component will start to heat up and adjust to the choosen temperature.

3. Temperature sensor (DHT 11) used for heat controling, which is generated by the heating components. When the heat has reached the choosen temperature point, the temperature sensor will send the temperature data and the microcontroller will order the heating component to stop working.

When the temperature has reached a certain point, the heating component will start working again. This automatic heating system uses the Switch Normally Close so that the temperature will not reach a human body heat threshold. Temperature is arranged in several modes ie low (30 ° C), medium (35 ° C) and high (40 ° C).

4. Vibrator will work continuously, starts when the on / off button is turned on and will stop when the on / off button is turned off. The vibration frequency to produce a relaxation effect can also be adjusted according to the capabilities of each patient's body.

5. Aromatic sprayer will be active based on timer work. Every 5 minutes, the timer will trigger the microcontroller to order the sprayer to spray aromatherapy. The timer will stop working when the tool is turned off. When the user finishes using it, then the on / off button is pressed to turn off the tool.

Figure 2. MP-RELAXIN Device Design.

MP-RELAXIN Device component description: 1. Microcontroller is a chip that act as a controller.

2. Battery, as a power source to supply power to all components.

3. Temperature sensor, to convert the magnitude of the temperature into an electrical quantity so that it can be measured.

4. Button, as a device activator and temperature adjustor.

5. Timer, as a timer.

6. LCD, used as both temperature and timer viewer.

7. Heater components, as a heat source to provide hydrotherapy replacement therapy 8. Vibrator, as a vibration producer and massage effect to provide relaxation to the user.

9. Aromatic sprayer, to provide aromatherapy for user of the tool.

10. Maternity Support Belt as a placement of MP-Relaxin and as the support of the body of the abdomen, so gravity will not centered on the abdomen and reduce lordosis in pregnant women.

Potential theurapeutic effect of allicin from aged garlic extract on malaria in pregnancy

Figure 3. Flowchat work mechanism MP-Relaxin

3.2 Tool Procedures In its use, please pay attention into the procedures for MP-RELAXIN device, in order to use this device at its best function as a pregnancy pain reliever. Here are the special procedures that need to be noticed by the user.

Figure 4. Illustrasion Device in woman preganancy

1. The device locates in the medial back (middle) of pregnant women between the necks to the pelvis.

2. Using the devices on the abdomen (stomach) pregnant women is prohibited, because it will have a negative impact on the mother and the fetus inside.

3. Frequency of vibration and heat temperature can be adjusted until the pain is not bothering the pregnant women.

4. Aromatherapy can be refilled, so the user can refill aromatherapy oil by using the chosen fragrance.

Recommendation of aroma options are orange aurantium or bitter orange, effleurage rose, and lavender essence.

5. There is no minimum or maximum time limit used, because this device has been designed using automatic sensors that can operate safely. However, 30-minute usage is recommended.

3.3 Testing Tools In vivo preliminary test has been done. The device was applied directly to a pregnant woman with paying attention in procedure of use. Device using should be accompanied by skilled health officer. In assessing the effectiveness of therapeutic tools, the NOSTIC Rating Scale (NRS) was used to calculate the level of pain based on the questionnaire given before and after the use of the tool. In addition, pain observation obtained from seeing the expression of pregnant women (Utami and Nurul, 2013).

4. CONCLUSION This tool is expected to help relieving pain in pregnancy and before the birth more effectively so that pregnant women do not feel disturbed and can remain active. It uses vibration-based technology, thermal temperatures, and aromatherapy combined into a set of device. The main components used in this tool are microcontroller¸ temperature sensor (DHT 11) which act as a heat controller, vibrator, and aromatic sprayer. When the heat has reached the chosen temperature point, the temperature sensor will send the temperature data and the microcontroller will order the heater component to stop working. This automatic heating system uses the Switch Normally Close so the temperature will not reach the human body heat threshold. Frequency of vibration to produce relaxation effect can also be arranged according to individual body capability. Aromatic sprayer is active based on timer work. Every 5 minutes, the timer will trigger the microcontroller to command sprayer spray aromatherapy. This device is used in the medial part of the back of pregnant women. Frequency of vibration, aromatherapy, and hot temperatures can be adjusted by the user. Aromatherapy can be refilled using a flavor favored by the user. In testing the effectiveness of the tool, Numeric Rating Scale (NRS) is used to calculate the degree of pain based on the questionnaire given before and after the use of the tool. In addition, the observation of pain is obtained by looking at the expression of pregnant women. Target market MP-Relaxin is pregnant and maternal women who need quick treatment to overcome the pain of pregnancy and childbirth. Our current focus is product refinement, patent acquisition, and mass production. We will collaborate with IMERI, IBI, IDI, POGI, puskesmas, hospitals, posyandu, and even Kemenkes for socialization based on community. We use long term customer relationship method by connecting network user platform.

5. REFERENCES 1.

Shalini, Shah; Esther, T Banh; Katharine, Koury; Gaurav, Bhatia; Roneeta,Nandi;Padma, Gulur.

2015.Pain Management in Pregnancy: Multimodal Approaches. Pain Research and Treatment. Vol. 2015. Article ID 987483, 15 pages. doi:10.1155/2015/987483

2.

Wiknjosastro, Hanifa. 2002. Ilmu Kebidanan. Jakarta: Yayasan Bina Pustaka Sarwono Prawirohardjo.

3.

Vermani, E; Mittal, R; Weeks, A. 2010. Pelvic girdle pain and low back pain in pregnancy: a review.

Pain Practice. 10: 60–71.

4.

Robinson, H.S; Eskild, A; Heiberg, E; Eberhard-Gran, M. 2006. Pelvic girdle pain in pregnancy: the impact on function. Acta Obstetricia et Gynecologica Scandi-navica. 85: 160–164.

5.

Ali, B; Al-Wabel, N.A; Shams, S; Ahamad, A; Khan, S.A; Anwar F. 2015. Essential oils used in aromatherapy: a systematic review. Asian Pac J Trop Biomed. 5 (8): 601-611.

6.

Cunningham, F.G. et al. 2010. Williams Obstetrics, 23rd Ed. Jakarta: EGC.

7.

Gallo, Rubneide; Barreto, Silva et al. 2013. Massage reduced severity of pain during labour: a randomised trial. Journal of Physiotherapy.59: 109-116.

8.

Koensoemardiyah. 2009. A-Z Aromaterapi untuk Kesehatan, Kebugaran, dan Kecantikan. Yogyakata: ANDI.

9.

Maddzalozzo, G.F; Kuo, Brian; Maddalozzo, W.A; Maddalozzo, C.D; Galver, J.W. 2016. Comparison of 2 Multimodal Interventions With and Without Whole Body VibrationTherapy Plus Traction on Pain andDisability in Patients With NonspecificChronic Low Back Pain. J Chiropractic Med. http://dx.doi.org/10.1016/j.jcm.2016.07.001.

THE ALTERNATIVE ANTIBIOTIC THERAPY FOR PRETERM PREMATURE RUPTURE OF MEMBRANE USING BANYAN HANGING ROOTS (FICUS BENJAMINA): INSILICO AND INVITRO STUDIES Putu Ijiya Danta Awatara1, Putu Sri Maharani Utami2, Desak Gede Yuliana Eka Pratiwi3, Adisty Aulia Kamarani4 University of Brawijaya

Aim: To determine the antimicrobial effects for Banyan Hanging Root Extract (Ficus benjamina) as an alternative treatment of preterm premature rupture membrane caused by Staphylococcus aureus bacteria by invitro and insilico.

Background: Infection is giving 32.53% of maternal death according data that was collected in 2015.

Studies showed that infection of Staphylococcus aureus causes the preterm premature rupture membrane associated with premature birth and neonatal disease. In fact, progress in infection control is threatened by the rapid development and spread of antibiotic drug resistance. Flavonoid and Tannin extracted from Banyan Hanging Root (Ficus benjamina) is a major biologically active component to inhibit nucleic acid synthesis and destruct bacterial cell walls. Flavonoid and tannin has an important role in controlling Staphylococcus aureus growth and incident of infection in maternal and neonatal health.

Material and Method: The research design that is used is pure experimental research (true experimental) with post-test only control group design. The study focused on the state of Staphylococcus aureus bacteria with the treatment of ethanol extract of the banyan hanging root (Ficus benjamina) in vitro by the wells diffusion method. Insilico (computation) research was needed by using data that exist in online database. Operation system that was used is Microsoft Windows 10 with Google Chrome browser verse 53.0.2785.116 m, Pyrx 8.0, Pymol, Vega ZZ, and Discovery Studio.

Results & Discussion: The result from the analysis of invitro (using well diffusion method) shows the effectiveness of Banyan Hanging Roots Extract (Ficus benjamina) in inhibiting the growth of Staphylococcus aureus is generally in line with the increase of extract concentration. Administration of Banyan Hanging Roots Extract (Ficus benjamina) against Methicillin-Resistant Staphylococcus aureus showed that the inhibition zone at the lowest concentration 5% is 6.74 mm and at the highest concentration 100% is 19.40 mm. The result from the analysis of insilico (supported by pyrex software) shows tannin strongly binds to LasR in their amino acid active site such as Tyr sequence 56, trp 60 (a) Asp 73, Try 75, Ser 129. The binding affinity among tannin and LasR amino acid is -7.8 kcal / mol 3.7 kcal/mol as the highest score and the lowest one is -7.1 kcal / mol.

Conclusion: Banyan Hanging Roots Extract (Ficus benjamina) has an antimicrobial effect and can be an alternative treatment for preterm premature rupture membrane caused by Staphylococcus aureus using invitro and insilico method.

Keywords: Staphyloccus aureus, Preterm premature rupture of membrane, Antibiotic, Flavonoid, Tanin, Ficus benjamina, Extract, Invitro, Insilico

Author: 1

Putu Ijiya Danta Awatara 081232270119 ijiyadanta19@gmail.com

2

Putu Sri Maharani Utami 082144003396 dindamaharani369@gmail.com

3

Desak Gede Yuliana Eka Pratiwi 082145907203 yulianapratiwidesak@gmail.com

4

Adisty Aulia Kamarani 081290300233

adistysunardi@gmail.com

THE ALTERNATIVE ANTIBIOTIC THERAPY FOR PRETERM PREMATURE RUPTURE OF MEMBRANE USING BANYAN HANGING ROOTS (FICUS BENJAMINA): INSILICO AND INVITRO STUDIES

by:

Putu Ijiya Danta Awatara

batch 2014

Putu Sri Maharani Utami

batch 2016

Desak Gede Yuliana Eka Pratiwi

batch 2016

Adisty Aulia Kamarani

batch 2016

FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY MALANG 2017

1. INTRODUCTION

Maternal and child mortality is a major problem for every country in the world. Based on data from the WHO in 2016, it was recorded that about 830 women died due to pregnancy or complications related to the birth of children every day around the world. One of the targets of Sustainable Development Goals on point 3 aims to reduce maternal mortality globally in ratios below 70 out of 100,000 births. The deaths of women during pregnancy as well as during childbirth are mostly due to complications. About 75% of the complications that cause the mother's death are caused by several things including severe bleeding, infection, high blood pressure during pregnancy (pre-eclampsia and eclampsia), complications during childbirth and unsafe abortion.[1] Approximately 32.53% of maternal deaths are caused by infection.[2]Infection is the invasion and multiplication of microorganisms such as bacteria, viruses and parasites that should not be present in the body. Staphylococcus aureus is a gram-positive bacterium that causes various infections in the tissues. Recent studies prove that Staphylococcus aureus causes the chorioamniotis and preterm premature rupture membrane associated with premature birth and neonatal disease. Based on previous studies in RSUD Dr. Saiful Anwar Malang, in 2010-2013, the proportion of preterm premature rupture of membrane events was 20% of 13,600 pregnant women who came to RSUD Dr. Saiful Anwar. While in Indonesia itself, the incidence of preterm premature rupture of membrane is 35.7% - 55.3% of 17,665 births.[3,4] Staphylococcus aureus infects and forms biofilms on the choriodecidual surface of the explored human granular membrane. Along with that, Staphylococcus aureus produces the proinflammatory cytokines that can interfere maternal and fetal conditions during pregnancy.

Therefore, increasing immunologic response to Staphylococcus aureus infection during pregnancy can decrease infectious diseases mainly caused by Staphylococcus aureus. [4] Most of the Staphylococcus aureus strains have now been resistant to penicillin, and Methicillinresistant Staphylococcus aureus (MRSA) has been common in hospitals and other public health centers.

The main therapeutic regimen for MRSA infections nowadays is Vancomycin. MRSA resistance to antibiotics Penicillin and Cephalosporin is causing the therapy with both of these antibiotics are no longer used. Nevertheless, MRSA resistance to Vancomycin has also started to occur. In 2013, Gardete et al, mentioned that some strains of Staphylococcus aureus have a tendency to develop into being resistant to Vancomycin through several alternative genetic pathways.[5] In recent years, there has been a lot of research on the potential of the banyan plants (Ficus benjamina) as candidates of antimicrobial agents. Banyan (Beringin) is still rarely utilized by humans but has enormous potential in medical therapy[6]. From all parts of the banyan tree, the hanging root part is one of the most active parts. Analysis of bioactive content in the section shows a variety of bioactive content, one of which is a flavonoid that can be an antimicrobial agent through a mechanism of inhibiting nucleic acid synthesis and disrupting the function of cytoplasmic membranes. Both of these mechanisms can cause disturbance to the energy metabolism of bacteria, causing the bacteria to

lysis.[7] Besides flavonoid, banyan’s hanging root also contains tanin. Tanin has been proven to inhibit bacterial growth by destructing bacterial cell walls, thus disrupting the permeability of cells that will cause bacterial cell death. [8,9] Based on these data, it is possible that the banyan hanging root (Ficus benjamina) has antimicrobial effects, including Staphylococcus aureus. The study was conducted to determine the antimicrobial effects of ethanol extract of banyan hanging root (Ficus benjamina) on growth of Staphylococcus aureus bacteria in vitro. In addition, the in silico method is used to determine the mechanism of inhibition of Staphylococcus aureus bacteria by ethanol extract of hanging roots, through biomolecular, using computer simulation. Through this study, the authors hope that this plant can be an alternative antimicrobial in the treatment of infection, mainly due to Staphylococcus aureus.

2. RESEARCH METHODOLOGY

The research design that is used is pure experimental research (true experimental) with post- test only control group design. The study focused on the state of Staphylococcus aureus bacteria with the treatment of ethanol extract of the banyan hanging root (Ficus benjamina) in vitro by the wells diffusion method. This research uses 7 kinds of treatment that is ethanol extract of banyan hanging root (Ficus benjamina) on 50%, 60%, 70%, 80%, 90%, 100% of concentrarion and distilled water as a control, with 4 repetitions on each concentration.

At In silico (computation) research was needed by using data that exist in online database. The website address can be freely accessed by using computer that connects with internet. Operation system that was used is Microsoft Windows 10 with Google Chrome browser verse 53.0.2785.116 m, Pyrx 8.0, Pymol, Vega ZZ, and Discovery Studio.

3. RESULTS This study was conducted by using several concentrations of Banyan Hanging Roots Extract (100%, 50%, 25%, 20%, 15%, 10%, and 5%). The effectiveness of antimicrobials of Banyan Hanging Roots Extract on bacterial growth Staphylococcus aureus was tested by well diffusion method.

Differences in antimicrobial effect were determined by the large diameter of the bacterial inhibition zone formed on Mueller Hinton Agar medium that had been mixed with Staphylococcus aureus. MHA medium were perforated by using sterile perforator to form 6 mm well diameter. The well was dropped with a Banyan Hanging Roots Extract and incubated 18-24 hours with 370C temperature.

Figure 1. Inhibition Zone formed in Mueller-Hinton Agar after being given Banyan Hanging Roots Extract using Well Diffusion Method

The inhibition zone formed in each concentration produce a different diameters (Figure 1). The calculation result of the average inhibition zone of root banyan root extract is presented in Figure 2.

Results Graph 25

19.4

20

14.64

Inhibition Zone (mm)

15 11.88 10.68 9.35

10 6.74

7.76

5%

10%

5

0 15%

20%

25%

50%

100%

Concentration of Banyan Hanging Root Extract (%)

Figure 2. The Average of Inhibition Zone after being given Banyan Hanging Roots Extract

(A)

(B)

(E)

(C)

(D)

(E)

Figure 3. Pharmacodynamics result [ Bonding Affinity (A, Left) Health Effect (B, Right) Target Prediction (C, Below), The Molecular view of tannin and LasR bond, (D and E)].

Picture A shows the bonding affinity result as much as -7,8 kcal/mol. This bonding has strong value.

Picture B shows the target prediction of Hanging Roots Extract (Ficus benjamina) in inhibiting Staphylococcus aureus. From picture above , it showed that Hanging Roots Extract (Ficus benjamina) inhibit/block LasR protein of Staphylococcus aureus. Picture C shows health effect. Health effect shows how much dangerous Banyan Hanging Roots Extract (Ficus benjamina) to organ. From picture above, showed that Hanging Roots Extract could give a significant effect to Membrane Integrity Agonist, Sugar phosphatase inhibitor, and Membrane Permeability Inhibitor. This is in line with protein location that become a target which is LasR. Picture D and E shows shows The Molecular view of tannin and LasR bond.

Tannin can binds to the amino acid of LasR in bacteria cell such as Tyr sequence 56, trp 60 (a) Asp 73, Try 75, Ser.

(A)

(C)

(B)

(D)

(E)

Figure 4. Pharmacokinetics result [ Lipid Solubility (A, Left) Water Solubility (B, Right) Bioavability (C and D, Below), Lethal Dose (E)].

4. DISCUSSION

Insilico has two outcomes, pharmacokinetic and pharmacodynamics. Pharmacodynamics result showed that, The Agonist integrity membrane, a sugar phosphatase inhibitor, membrane permeability inhibitor is the target of tannin in the bacteria cells. This result is consistent with our study which showed that tannins can damage bacterial membranes. The pathway ( Figure 3 ) showed that Tanin can inhibit LasR on its active side so that when the LasR inhibited, it can inhibit the membrane integrity by disrupting glycoprotein formation on the membrane cell and biofilms biosynthesis bacteria. The docking results show -7.8 kcal / mol to -7.1 kcal / mol. This result shows the bond between tannin and LasR is difficult to be distracted. Tannin can bind to the active side of LasR. This is shown in figure 3 where the surface of the active side of the protein can bind to the tannin. The Molecular view shows that tannin can binds to the amino acid of LasR in bacteria cell such as Tyr sequence 56, trp 60 (a) Asp 73, Try 75, Ser 129.

Pharmacokinetic results showed that the tannin is soluble in lipid and slightly soluble in water.

The logP value of this compound is 5.12 so the compound will penetrate into the cell nucleus. While solubility against water is very weak but when it soluble, the high solubility rate is 62.1 mg / ml. The bioavability of tannins showed that tannin is difficult to absorb in the duodenum. But tannins are easily soluble in the stomach and stable at pH below 2. The first pass metabolism in the liver predict that tanni ns are easily metabolized so that they are distributed very little. When tannins are absorbed, it will undergo an active transport and do not experience passive transport, so if it is transmitted, tannins requires an ATP. After it absorbed, tannins will be distributed in the blood through albumin. Lethal dose value of tannins is showed a moderate reliability when administrated through Intraperitoneal, Oral, Subcutaneous routes and Borderline Reliability through intravenous route. Insilico is preliminary data in determining dose for further research using invitro and insilico methods In vitro studies aims to determine the effectiveness Banyan Hanging Roots Extract (Ficus benjamina) against Staphylococcus aureus in vitro using well diffusion method. The results were obtained by measuring the inhibiton zone of bacterial growth and measured by using vernier caliper (mm). The inhibition zone is a clear area or visible region around the well. The larger the inhibition zone diameter, indicate the greater the antimicrobial effect.

Administration of Banyan Hanging Roots Extract (Ficus benjamina) against Methicillin-Resistant Staphylococcus aureus showed that the inhibition zone at concentration 5% is 6.74 mm, 10% is 7.76 mm, 15% is 9.35 mm, 20% is 10.68 mm, at 25% is 11.88 mm, 50 % is 14.64 mm and 100% is 19.40 mm. It shows that the effectiveness of Banyan Hanging Roots Extract (Ficus benjamina) in inhibiting the growth of Staphylococcus aureus is generally in line with the increase of extract concentration.

Normality test and homogeneity test showed that the samples were distributed normally and homogeneous so that parametric statistical tests could be performed. Based on One-Way ANOVA statistical test results obtained a significance value of 0.000 (p <0.05). These results are supported by the Post Hoc Tukey test. The results of both tests showed that different concentrations of ethanol extracts of banyan root roots (Ficus benjamina) have a significant effect in inhibiting the growth of Staphylococcus aureus in vitro by using well diffusion method.

Pearson correlation test showed a significance of 0,000 (p <0.01) and R = 0.946 positive direction, so that there was a significant correlation between Banyan Hanging Roots Extract (Ficus benjamina) against Staphylococcus aureus. Increasing concentration of Banyan Hanging Roots Extract (Ficus benjamina) will increase the diameter of inhibition zone of bacterial growth Staphylococcus aureus. Regression test showed that the possibility of MRSA growth inhibition caused by Banyan Hanging Roots Extract (Ficus benjamina) administration was 89.6%.

Increasing diameter on inhibitory zone of Staphylococcus aureus growth followed by increasing concentration of Banyan Hanging Roots Extract (Ficus benjamina). Based on the results of statistical test data that have a high significance value, it can be concluded that the Banyan Hanging Roots Extract (Ficus benjamina) effective as an antimicrobial against Staphylococcus aureus.

The growth inhibition of Staphylococcus aureus is due to the bioactive compounds contained in the extract of Banyan Hanging Roots Extract (Ficus benjamina). According to Jain et al.,2013, the active

compounds contained Banyan Hanging Roots Extract are flavonoids and tannins.[10] The extraction of leaves, roots, and fruits was isolated by Chromatography Columns produced various flavonoid compounds such ascinnamic acid, lactose, naringenin, quercetin, caffeic acid and stigmasterol.

Antimicrobial screening on compounds showed that quercetin and naringenin showed strong antimicrobial activity.[11] Flavonoids are able to inhibit bacterial metabolism through the inhibition of nucleic acid synthesis and disruption of cytoplasmic membrane function. This causes a disruption o f energy production in bacteria.[12] Tanin has been proven to inhibit bacterial growth by destructing bacterial cell walls, thus disrupting the permeability of cells that will cause bacterial cell death. [8,9] The results of this study are supported by the research conducted by Truchan et.al (2016). The results of the study stated that besides roots extract, the other parts of Banyan Tree such as leaves can also decrease the amount of growth of Methicillin-Resistant Staphylococcus aureus, Staphylococcus aureus, and Streptococcus pneumonia which categorized as a gram-positive bacteria, and Klebsiella pneumoniae

and Pseudomonas aeruginosa which categorized as a gram negative bacteria. It suggests that the Banyan Hanging Roots Extract (Ficus benjamina) categorized as broad-spectrum antimicrobial as it is effective ability against Gram positive and Gram negative bacteria.

Limitations that can be the background of further research is conduct the in vivo studies to determine the effective dose, toxicity, and side effects that can be caused by the Banyan Hanging Roots Extract (Ficus benjamina). Further research is important to underlie clinical application in humans, especially as an alternative therapy for Staphylococcus aureus infections.

5. CONCLUSIONS

From the research above, it can be concluded that: 1. The Banyan Hanging Roots Extract (Ficus benjamina) has an antimicrobial effect against Staphylococcus aureus in vitro and insilico 2. The Increasing concentration of the Banyan Hanging Roots Extract (Ficus benjamina) is directly proportional with the inhibitory zone diameter of Staphylococcus aureus growth.

3. Banyan Hanging Root Extract (Ficus benjamina) can be an alternative treatment of preterm premature rupture membrane caused by Staphylococcus aureus bacteria.

6. REFERRENCES 1. World Health Organization. 2016. Maternal Mortality Media Centre. Available from: http://www.who.int/mediacentre/factsheets/fs348/en/ (accessed in 21 October 2017) 2.

Halder, A.,Vijayselvi,R.,Jose,R. 2015. Changing perspectives of infectious causes of maternal mortality. Journal of The Turkish-German Gynecological Association, 16(4): 208–213. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4664211/ (accessed in 21 October 2017)

3. Winarsih,S., Kusumaning,R.,Nooryanto,M. 2015. Pola Bakteri dan Uji Kepekaan Antibiotik pada Preterm Premature Rupture of Membranes di RSUD dr. Saiful Anwar Malang Periode 20112013. Majalah Kesehatan FKUB 4. Doster,R., Kirk,L., Tetz,L. ,Rogers,L. ,Aronoff,M. ,Gaddy, J. 2016. Staphylococcus aureus infection of human gestational membranes induces bacterial biofilm formation and host production of cytokines. Journal of Infectious Diseases, 215(4), 653-657 5. Vidaillac C, Tewhey R, Sakoulas G, Kaatz GW, Rose WE, Tomasz A, Rybak MJ. 2013.

Alternative mutational pathways to intermediate resistance to vancomycin in methicillin-resistant

Staphylococcus aureus. US National Library of Medicine, 208(1):67-74 6. Truchan M., Tkachenko H., Buyun L., Sosnov- skyi Y., Prokopiv A., Honcharenko V., Osadowski Z. (2015). Bacteriostatic activity of extracts from lea- ves of Ficus spp. on Staphylococcus aureus growth. 1(8). 546–550 7. Abreu,C., Serra,C., Borges,A., Saavedra,M., Mcbain, A., Salgado,A..,& Simões,M. Microbial Drug Resistance. December 2015, 21(6): 600-609. https://doi.org/10.1089/mdr.2014.0252 8. Akiyama, H., Fujii, K., Yamasaki, O., Oono, T., & Iwatsuki, K. 2001. Antibacterial action of several tannins against Staphylococcus aureus. Journal of antimicrobial chemotherapy, 48(4), 487-491.

9.

Rini J, Esko J, Varki A. Glycosyltransferases and Glycan-processing Enzymes. In: Varki A, Cummings RD, Esko JD, et al., editors. Essentials of Glycobiology. 2nd edition. Cold Spring Harbor (NY): Cold Spring Harbor Laboratory Press; 2009. Chapter 5. Available from: http://www.ncbi.nlm.nih.gov/books/NBK1921/ (accessed in 25 September 2017)

10. Jain, A., Ojha, V., Kumar, G., Karthik, L., & Rao, K. B. V. 2013. Phytochemical composition and antioxidant activity of methanolic extract of Ficus benjamina (moraceae) leaves. Research Journal of Pharmacy and Technology, 6(11), 1184-1189.

11. Almahy, H. A., Rahmani, M., Sukari, M. A., & Ali, A. M. 2003. The chemical constituents of Ficus benjamina Linn. and their biological activities. Pertanika J. Sci. Technol, 11(1), 73-81.

12. Cushnie, T. T., & Lamb, A. J. 2005. Antimicrobial activity of flavonoids. International journal of antimicrobial agents, 26(5), 343-356.

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SCIENTIFIC PAPER ABSTRACT The Safety of Anastatica hierochuntica as an Agent to Assist Birth Delivery Sebelas Maret University Ratna Bintari, Apta Devi Nurul Nafisa, Nur Irfani Agita Suwarna Aim To improve the lives of women, men, and children due to the MDGs and SDGs, this scientific paper is written in order to explain the predisposition factors of maternal morbidity and mortality, and more likely focus on the problem caused by intervention given, so that it can be solved in a more effective way.

Background In a developing country, the usage of herbal medicine, especially Anastatica hierochuntica, are very popular in public and among the primary health care providers, but it does not get much attention although the safety and efficacy towards pregnancy has not been proven yet because of the limited studies. Any forms of medical intervention related to childbirth also needs evaluation.

Material and Methods We conducted a comprehensive search of some systematic reviews, article, and experimental studies published in NCBI using the combination of these following terms: Anastatica hierochuntica, oxytocin, herbal, labor, and pregnancy. Titles and abstracts were reviewed for possible inclusion and exclusion. We also read the full article of the selected titles and abstracts then checked the reference list for more information sources.

Results Based on a study conducted to assess more about the herbal usage during pregnancy, Anastatica hierochuntica are found out to be the most popular herb. The study focused on statistical analysis and elemental analysis. The statistical analysis revealed that majority of pregnant women were using herbal medicine because the beliefs that herbal products do not contain harmful chemicals. Despite the fact that most of them are aware about the adverse effects towards the unborn babies that may follow, the practice continues without enough knowledge. From elemental analysis, Anastatica hierochuntica contain useful minerals that beneficial for pregnancy.

The Anastatica hierochuntica are claimed to be highly recommended for antepartum care, eases childbirth, reduces uterine hemorrhage, and facilitates expulsion of a dead fetus. But some obstetricians in developing countries noticed that majority of hemorrhage cases in postpartum women have history of Anastatica hierochuntica consumption.

Conclusion Any interventions of labor and birth, including the uses of herbal medicine and medical intervention without a clear indication, have some adverse effects for the mother and babies. As a medical students, we need to conduct further researches and studies about the Anastatica hierochuntica together with the medical professionals. Evaluation of standard maternity care is an obligation for the government. Childbirth education for any pregnant women will be essential to improve the quality of labor and birth delivery.

SCIENTIFIC PAPER The Safety of Anastatica hierochuntica as an Agent to Assist Birth Delivery Sebelas Maret University Ratna Bintari, Apta Devi Nurul Nafisa, Nur Irfani Agita Suwarna

Introduction

The usage of herbal medicine in a developing country are very popular, including the one that is believed can facilitate labor. The most common herbal medicine used during pregnancy is Anastatica hierochuntica (in Indonesia we call it Rumput Fatimah or Grass of Fatimah). It is very popular both in public and among the primary health care providers, but it does not get much attention although the safety and efficacy towards pregnancy has not been proven yet. There is still limited studies about this dessert plant which is leaving so many unanswered questions. The practice of herbal medicine usage has been developed and handed down from generation to generation based on the theory, beliefs, experience, and testimony.

Apart from that, any forms of medical intervention related to childbirth also needs evaluation. The health care providers, especially obstetricians and midwives, have the important role connected to this issue. The pregnant women itself should understand about pregnancy and childbirth for the sake of herself and the babies.

Material and Methods We conducted a comprehensive search of some systematic reviews, article, and experimental studies published in NCBI using the combination of these following terms: Anastatica hierochuntica, oxytocin, herbal, labor, and pregnancy. The search covered the period from 2009 until 2017. Titles and abstracts were reviewed for possible inclusion and exclusion.

We also read the full article of the selected titles and abstracts then checked the reference list for more information sources.

Results From a cross-sectional, descriptive study conducted in Malaysia by Sooi and Keng, [1] the herbal usage during pregnancy is common in developing countries. The respondents include Malay pregnant women in the last trimester and women within two-days after childbirth. The study is focus on statistical analysis to determine the prevalence and use of herbal medicines during pregnancy and elemental studies towards the most common herbal products used. The result of statistical analysis from 460 respondents are grouped according to specific variable: sociodemographic (age, occupation, education, income), trimester of pregnancy, dose of herbal medicines, information sources, reasons, sources of herbal medicines, and the type of herbal medicines.

The correlation between sociodemographic and herbs consumption found out to be significant in particular aspects only: age and income (Table 1).

Table 1 Relationship between sociodemographic characteristics and herbal medicines use during pregnancy Characteristic

Herbal users n (%)

Herbal non-users n (%)

X2 stat (df)

48 (10.4) 110 (23.9)

180 (39.1) 122 (26.6)

19.20

<0.001*

97 (21.1) 61 (13.2)

181 (39.4) 121 (26.6)

4.89

0.087

107 (23.3) 14 (3.0) 37 (8.0)

190 (41.3) 44 (9.6) 68 (14.8)

3.09

0.213

P value

Age <30 >30 Occupation Unemployed Employed Education Primary Secondary Tertiary

Income <RM1000 RM1000-RM3000 >RM3000 Gravidity Primid 2-5 6 and above *P < 0.05

91 (19.8) 52 (11.3) 15 (3.2)

207 (45.0) 78 (17.0) 17 (3.7)

22.44

<0.001*

24 (5.2) 91 (19.8) 43 (9.3)

78 (17.0) 172 (37.4) 52 (11.3)

10.32

0.006*

Data about administration during pregnancy (Table 2) showed that most of the respondents were using the herbs during labor (73.4%), minute number in first semester (7.6%), and none of them administered the herbs in second trimester.

Table 2 Use of herbal medicines according to the trimester of pregnancy Gestation period

N

% of total respondents

During 1st trimester

12

7.6

During 2nd trimester

0

0

During 3rd trimester

28

17.7

During entire pregnancy During labor

2 116

1.3 73.4

The study turned out that some of the respondents were unsure about the dose of herbs they consumed daily (Figure 1).

Figure 1 Amount of herbal medicines consumed daily

The interesting part is the source of information about herbal medicines (Table 3). Majority of respondents know it from their parents (60.8%), followed by traditional midwives (10.1%), friends (10.1%), relatives (9.5%), parents-in-law (5.1%), mass media (1.9%), company (1.9%), and healthcare provider (0.6%).

Table 3 Information source of herbal medicines Parents Traditional midwives Friends Relative Parents in-law Mass media Company Healthcare providers Information Source

96 16 16 15 8 3 3 1 N

60.8 10.1 10.1 9.5 5.1 1.9 1.9 0.6 %

The main reason why they choose to consume herbal products during their pregnancy is to facilitate labor. This is followed by a promotion of health status, traditional practice and to relieve common discomfort during pregnancy, to keep warm, to keep sexual pleasure, to restore youth, to prevent whitish discharge, and to promote fetal physical health and intelligence. The percentage are shown in the table below (Table 4).

Table 4 Common reasons for herbal medicinal usage during pregnancy (n = 158) Reasons

Yes n (%)

No n (%)

Facilitate labor

141 (89.2)

17 (10.8)

Promote health status

49 (31.0)

109 (69.0)

Traditional practice

36 (22.8)

122 (77.2)

Relieve common discomfort during pregnancy Keep warm Sexual pleasure Restore youth Prevent whitish discharge Promote fetal physical health and intelligence

17 (10.8)

141 (89.2)

17 (10.8) 11 (7.0) 11 (7.0) 10 (6.3) 9 (5.7)

141 (89.2) 147 (93.0) 147 (93.0) 148 (93.7) 149 (94.3)

From the questionnaire, it is known that pregnant women can easily get herbal medicines by buying it directly from traditional midwives, store and self-preparations, also from herbal shops (Figure 2).

Figure 2 Sources of herbal medicines

The statistical data also reported that Anastatica hierochuntica is the most popular herbs commonly used during pregnancy (60.1%) based on the result of the survey (Table 5).

Table 5 Most common herbal medicines use during the pregnancy period Types of herb

N

%

S. Fatimah (Anastatica hierochuntica L.)

101

63.9

Minyak Selusuh ( Coconut Oil)

53

33.5

Unidentified Herbs

10

6.3

Halia (Zingiber officinale)

5

3.2

Bawang Merah (Allium ascalonicum)

5

3.2

Bawang Putih (Allium sativum)

4

2.5

Serai (Cymbopogon citratus)

4

2.5

Kunyit (Curruma longa)

2

1.2

Manjakani (Croton caudatus)

2

1.2

Inai (Lawsonia inermis)

2

1.2

Sirih (Piper betle L.)

2

1.2

Jarum Mas (Striga asiatica)

2

1.2

Pegaga (Centella asiatica L.)

1

0.6

Sepang (Caesalpinia sappan)

1

0.6

Homeopathy

18

11.4

Build up on the statistical data, an elemental analysis then be held to dried branches, flowers, and grounded forms of Anastatica hierochuntica. As a preparation, the Anastatica hierochuntica were cyclically dehydrated by washing it using variation of ethanol concentration (75%, 95%, and 100%) for 15 minutes each. Following the process, anastatica hierochuntica were removed from ethanol and dried by hexamethyl-disilazane evaporative technique for 10 minutes and then redried in specimen plate for about half an hour. A coating within the sputter will be the last step preparations of specimens.

The digital stereomicroscope images were taken using Energy Dispersive X-ray (EDX). This examination showed that Anastatica hierochuntica had useful minerals such as calcium (Ca), magnesium (Mg), aluminum (Al), potassium (K), zinc (Zn), and iron (Fe), apart from the major number of carbon (C), oxygen (O), and silica (Si). The distribution are different in every part of Anastatica hierochuntica (Table 6). It would be the key to decide what part of Anastatica hierochuntica that will be utilized.

Table 6 EDX weight and atomic percentage of the various elements detected in Anastatica hierochuntica L. Branch 1 Element

Stigma

Weight

Atomic

%

%

CK

38.78

48.13

OK

49.31

Al K

Element

Stem

Weight

Atomic

%

%

CK

35.19

46.77

45.95

OK

42.73

2.18

1.21

Mg K

Si K

6.89

3.66

Ca K

2.84

1.05

Element

Weight

Atomic

%

%

CK

16.98

24.81

42.63

OK

52.42

57.50

0.85

0.56

Mg K

1.25

0.90

Al K

3.61

2.13

Al K

5.09

3.31

Si K

7.19

4.09

Si K

18.51

11.57

KK

1.19

0.49

KK

1.33

0.59

Ca K

6.11

2.43

Ca K

0.78

0.34

Fe K

3.14

0.90

Zn K

3.64

0.98

Totals

100.00

Totals

100.00

Totals

100.00

Element

Branch 2 Weight %

Atomic %

Element

Flower Weight %

Atomic %

Element

Powder Weight %

Atomic %

CK

39.52

50.12

CK

17.96

26.59

CK

42.10

50.31

OK

46.73

44.49

OK

46.35

51.52

OK

53.72

48.20

Si K

1.01

0.55

Mg K

0.39

0.29

Ca K

4.18

1.50

Ca K

12.74

4.84

Al K

1.67

1.10

Si K

31.10

19.70

Fe K

2.53

0.80

Totals

100.00

Totals

100.00

Totals

100.00

The minerals found in Anastatica hierochuntica play important role to maintenance human health and also beneficial for pregnancy. Additionally, according to Lothian, [2] the pain of labor is what most women worry about. Calcium itself plays critical role in nerve and muscle regulation, so it will work along with magnesium to regulate uterus contraction and expected to reduce pain. This could explain why pregnant women are consuming the herbal medicine that is believed can encourage healthy pregnancies.

The Anastatica hierochuntica is widely consumed as a tea beverage. It is powdered and then mixed with honey as a remedy for difficult childbirth and uterine hemorrhage. In addition, it is also beneficial in treating asthma, gastrointestinal disorders, depression, high blood pressure, indigestion, headache, cold, fever, malaria, epilepsy, fatigue, diabetes, heart disease, and infertility. [3] The continuous used of Anastatica hierochuntica as traditional medicine is caused by the cultural belief that it is highly recommended for antepartum care, eases childbirth, reduces uterine hemorrhage, and facilitates expulsion of a dead fetus. The testimony stated that it has anti-oxidant, [4] anti-microbial, and hypoglycemic properties too. [5,6]

Some healthcare professional have hypothesis that the action of Anastatica hierochuntica is agonist to oxytocin, based on the same effect that can be produced: the uterine contracting or oxytocin effect and the blood pressure lowering effect which is controlled by calcium [1,7].

But if the administration of this herbs is in wrong dose and timing, it might be fatal. Some obstetricians noticed that majority of hemorrhage case in postpartum women have history of Anastatica hierochuntica consumption. This may happen because the uterine hyper-stimulation and over induction of labor that cause rupture of the uterus. But once again, there is still lack of evidence about the mechanism of this herb so it must be assessed later.

The high prevalence of utilization of Anastatica hierochuntica in the majority of pregnant women cannot be separated from the traditional beliefs that herbal products do not contain harmful chemicals like the common pharmaceutical drugs because the herbs are coming directly from nature.

Supported also by the practical experiences and observations that showed no significant adverse effects and has been going on for many generations. Even some studies stated that 4% to 62% of pregnant women continued to consume herbal medicines during her pregnancy despite the fact that they are lack of knowledge about the good and bad side of it. [1]

Data obtained from the study reveals that only a few women were aware of the possibility of the herbs being contaminated. Moreover, most of women know the adverse effects for the fetus that may follow: abortion, fetal growth retardation, premature delivery, malformation, and fetal death. But ironically, there is still some who believed that the practice is effective in increasing the well-being of the mother and fetus.

A high maternal mortality nowadays also caused by the medical intervention given (Figure 3).

The data shows that the most common maternal mortality is severe bleeding caused by the oxytocin and manual compression. [8] This is why evaluation of the current maternal care is needed.

Figure 3 Evidence-based interventions for major causes of maternal mortality. Other direct causes include ectopic pregnancy, embolism, and anesthesia-related complications. Indirect causes include anemia, malaria, and heart disease. Reproduced from USAID From the American People. Maternal and Child Health Web site.

Discussion

The usage of Anastatica hierochuntica has been widely known in developing countries for years.

It will be impossible to stop the usage because the practice has been passed down generation to generation and still continues. Not to mention that the products are easily found too. It leads to the urge of conducting more studies to assess the safety and efficacy of Anastatica hierochuntica towards maternal health. Evaluation on medical intervention also needed, regarding the fact that most of women trust the herbal medicine more than pharmaceutical drugs.

It is also stated before, that main reason of consuming herbal products is to facilitate labor. It has the strong association with the factors that determine how safe the pregnancy was. Birth is intended to happen simply without worry or trouble and medical intervention without clear indication will disrupt the physiologic process of birth. According to the World Health Organization (WHO) and Lamaze International, there are six key, known as Healthy Birth Practice, which promote, support, and protect normal birth. [9]

The first one is let labor begins on its own without any intervention, because it will be healthier and safer for both mother and baby. For this reason, avoid Anastatica hierochuntica consumption will be better. Then walking, moving around, and changing positions throughout labor will help labor progress, coping the pain, enhance comfort, and decrease the risk of complication. Bringing relatives for support is also essential. But remember, that as much as possible the relatives should understand which one is potentially benefit or harmful for the labor too, considering the survey that tell us about the majority of parents act as the main information source of herbal products administration.

Healthcare providers play a role in the safe birth by minimizing interventions that are not medically necessary, for an instance intravenous lines and electronic fetal monitoring restrict women’s ability to walk, change positions, and find comfort during contractions. The intravenous lines are not really needed when the women are able to eat and drink so she has enough energy to persevere during labor. The electronic fetal monitoring also can be replaced by intermittent auscultation.

The routine use of this technology will increase the risk of cesarean surgery instead, which has a longterm risks for the mother. Epidurals interfere that aimed to relief pain during labor also has negative effect. If there is no pain, the brain dos not get any signal to keep releasing oxytocin. Consequently synthetic oxytocin, called Pitocin, is needed. The administration of this synthetic oxytocin will affect molecular pathways and downstream that need to be assessed further. As well as the consumption of Anastatica hierochuntica that is also believed to have the same effect as oxytocin in inducing labor.

[10,11] For every healthcare providers, it is important to note that any interventions with no clear medical indications set a cascade for other interventions which can interrupt the normal childbirth and expose the women and unborn babies to unnecessary risks.

Laboring mother also recommended to avoid giving birth on the back, but better to follow the body’s urges to push rather than pushing in a directed way because it is mentioned before that manual compression may cause a severe bleeding. As the birth delivery succeeded, keep mother and baby together. It is best for mother, baby, and breastfeeding when the baby is placed skin-to-skin with his mother. It will make the early hours and days after birth safer for mothers and babies.

The other challenge concerning this maternal issue is the unreported use of herbal medication, more specifically Anastatica hierochuntica. Majority of women did not report their use of herbal medication to their doctor. In most cases they came to the doctor when severity occurs. They only tell their doctor about the history of herbal medications when being asked. Thus, healthcare providers must be aware if a pregnant women came and reported some problems. They need to ask about whether she consume herbal medications or not, especially the common herbal used in the country. If the healthcare providers knew the exact herbal product consumed, they can give appropriate educational intervention according to the bioactivity, mechanism, and other properties of the herb. More research should be conducted because there still massive usage of herbal medications even in this very modern era. Lack of evidence about the effect of herbs upon the pregnancy will make the assessment of maternal morbidity and mortality difficult. The study of the herb itself would be very beneficial to know the elemental content since many minerals play significant roles in the molecular pathways. Referring to the maternal mortality trends, the major causes are hemorrhage (27.1%) with more than 72.6% of it were classified as postpartum hemorrhage, hypertension (14%), sepsis (10.7%), abortive outcomes (7.9%), and embolism or other direct causes (12.8%). [12] It may lead to the ideas that Anastatica hierochuntica, which has an oxytocin effect, blood pressure lowering effect, and anti- microbial properties as stated before, are very potential to be used as an agent assisting childbirth and decrease maternal mortality ratio (MMR), especially a maternal mortality that caused by postpartum hemorrhage, hypertension, and sepsis. Those three are the most common cause of maternal mortality that may be handled because the presence of the oxytocin effect, blood pressure lowering effect, and antimicrobial properties consecutively. But the most important thing of utilization is about doses and timing of administration. The current challenge is to know more about these two crucial things that have not been widely studied.

The mortality ratio also depends on the presence of trained health personnel. The data below reveals that the presence of healthcare providers is inversely proportional to the maternal mortality ratio (Figure 4). [8] For this reason, a promotion of healthcare professional service is absolute.

Figure 4 Relationship between maternal mortality ratio and proportion of births attended by trained personnel in the Southeast Asian region, by country, 1995. Reproduced from World Health Organization Regional Office for South-East Asia. Health & Evidence Information Web site.

Conclusion

Any interventions of labor and birth, including the uses of herbal medicine and medical intervention without a clear indication, have some adverse effects for the mother and babies. As a medical students, we need to conduct further researches and studies about the Anastatica hierochuntica together with the medical professionals. In accordance to the effects of Anastatica hierochuntica that are potential to reduce the maternal mortality rate (MMR), many deep-related studies are needed for an optimal usage. Evaluation of standard maternity care is an obligation for the government. Childbirth education for any pregnant women will be essential to improve the quality of

labor and birth delivery. It will convince every mother that they can give birth without any intervention or fear. They also will be helped to understand more about how maternity care influence the health and safety of both mother and the baby.

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Prevalence, Prevention, and Treatment of Postpartum Haemorrhage in Indonesia Raymond Wangsa, Jonathan Ariel, Andika Prasetyo Arifin, Joseph John Rivaldo

Medical Students of Krida Wacana Christian University Abstract Background: Death due to pregnancy still become an important case especially postpartum haemorrhage (PPH). PPH is still unpredictable because only several cases that the risk factor of PPH can be identified. Our objective was to show the prevalence statistic data of PPH in Indonesia.

Methodology: The analysis used research journal such as a cross-sectional study basic health research (riskesdas) 2010, Indonesian population census in 2010, WHO 2014 and others.

Subjects that we used for this analysis are married women aged 13-49 years who had a probability of PPH history and gave birth of their last child between 1st January 2005 to August 2010 from riskesdas 2010 data and others research journal that provide significant data about the Post Partum Haemorrhage case.

Result: From this analysis, there is 3.1% of 19,506 women in Indonesia have PPH and most of them are on age 20-34 years old, also 10% of them had eclampsia then from the cencus 2010 analysis, the largest pregnancy-related death by single causes of death was given to PPH at 1526 (20,21%) from the 7550 weighted sample. Indonesia Department of Health 2002 also said that from 100,000 mothers that were born, 280 of them were died because of PPH. Indonesia ministry of Health 2010-2013 data also said MMR that was caused by PPH was declining from year to year. According to World Health Organization (WHO) report 2014, maternal mortality due to postpartum bleeding in the world was 289,000 inhabitants. Those data are maternal mortality data due to post-partum bleeding.

Conclusion: The prevalence of PPH in Indonesia is still very high. Certain actions are needed to reduce the high numbers, both from the government and medical implementers.

Researchers in Indonesia also must not stop in deepening this PPH case, especially in finding ways of prevention or treatment.

Keyword: Post partum haemorrhage, riskesdas, census, MMR

Prevalence, Prevention, and Treatment of Postpartum Haemorrhage in Indonesia Raymond Wangsa, Jonathan Ariel, Andika Prasetyo Arifin, Joseph John Rivaldo

Medical Students of Krida Wacana Christian University

Background The mortality that was caused by pregnancy still become an important case to talk about especially for mothers who gave birth prematurely throughout the world. 1 Death because of postpartum haemorrhage (PPH) occur at 1-5% from all birth in developed and developing countries are still the main cause of morbidity and mortality.1,3,5 Statistic data from WHO reveals that 25% of maternal deaths in the world are caused by PPH, so it can be said that one woman dies in every 4 minutes when the calculation indicates the number of 140,000 deaths per year.4 The amount of PPH percentage in sub-Saharan Africa region reaches 10.5% while the deaths caused by PPH in Uganda alone have reached 25%.2 PPH prevalence that occurred in Pakistan even reached a much larger number which is 34%.

From previously exposed data, it is clear that PPH is unpredictable and there was no single patient that is immune from the incident. 1 The stage of morbidity caused by PPH may also be associated with anemia, disseminated intravascular coagulation, blood transfusion, hysterectomy, and renal or hepatic failure.1,3 Risk factors of PPH alone include: previous PPH history, multiple pregnancy, older age, genital tract injury, no-use of oxytocics for PPH prophylaxis, cesarean birth and fetal death from intra-uterine devices.2,5 Only about one-third of PPH cases which risk factors can be identified.3

Methodology

This analysis used a cross-sectional study Basic Health Research (Riskesdas) 2010, The 2010 Indonesia Population Census, and many data that we got from other research journals. The health of pregnant women is one of the aspect in Riskesdas 2010. Because of that, this data was expected to be an evidence-based about Post Partum Haemorrhage (PPH). Many indicators that were collected in Riskesdas 2010 such as maternal and child health status, the

prevalence of malaria and tuberculosis, and others. Interviews and measurements was conducted to collect the data. The subjects are married women aged 13-49 years who had a probability of PPH history and gave birth of their last child between 1st January 2005 to August 2010.6 On the other hand, The 2010 Indonesia Population Census gave us the data about maternal death including case selection of the study, the age specific pregnancy-related death rate in Indonesia based on the residency classification, level of pregnancy-related death rate by characteristics, the timing and place of maternal deaths in Indonesia, the 25 largest proportion of pregnancyrelated death by single causes of death in Indonesia (2011), and others.7 We also get many journals and studies (from WHO 2014 analysis, Indonesia Demographic Health Survey or SKDI 2012, and Kemenkes 2010-2011 data analysis) that provide significant data about the Post Partum Haemorrhage case such as it contribution to mortality rate that we will try to compare.

They could gave us the data we need to compare with each other and that is what we want to do. For this analysis, we will try to combine as many data we can get and make a chart and diagram from it. From the chart and diagram, we will know the progress of Post Partum Haemorrhage in Indonesia. So basically, the method of acquiring the data is by searching, taking some data from it, and combining it.

Result There was a total of 91,711 subjects in Riskesdas 2010 samples which 59,382 of them were married. Based on the data, the total women with probability of having Post Partum Haemorrhage were 19,506 while 18,905 (96.9%) of them wouldn’t have PPH and the rest (3.1%) did have PPH. From that 3,1 %, mostly of them (68,5%) are between 20-34 years old and 10% of them had eclampsia. 6 From the cencus 2010 analysis, the largest pregnancy-related death by single causes of death was given to PPH at 1526 (20,21%) from the 7550 weighted sample. It was such a big number.7 Indonesia Department of Health 2002 also said that from 100,000 mothers that were born, 280 of them were died because of PPH. 8 Indonesia ministry of Health 2010-2013 data

also said MMR that was caused by PPH was declining from year to year. In 2010, PPH contributed 35,1 % MMR. In 2011, PPH contributed 31,9 % MMR. In 2012, PPH contributed 30,1 % MMR and in 2013, PPH contributed 30,3 % MMR. 3 Maternal mortality and morbidity are still a problem in developing countries to this day. According to World Health Organization (WHO) report 2014, maternal mortality due to postpartum bleeding in the world was 289,000 inhabitants. Some countries have a high maternal mortality rate (MMR) such as Africa at 179,000 people, South Asia at 69,000 inhabitants, and Southeast Asia at 16,000 inhabitants. Maternal mortality in Southeast Asian countries such as Indonesia at 190 / 100,000 live births, vietnam at 49 / 100,000 live births, Thailand at 26 / 100,000 live births, Brunei at 27 / 100,000 live births, and malaysia at 29 / 100,000 live births. 1

Based on the data obtained, AKI in Indonesia is still high compared to other ASEAN countries. According to Indonesia Demographic Health Survey (SKDI) 2012, MMR in Indonesia declined from 230 / 100,000 live births in 2007 to 209 / 100,000 live births, while the expected target under the Millennium Development Goals (MDGs) in 2015 (102 / 100,000 live births). This proves that MMR in Indonesia is still very high above the WHO target set about twice as big as the WHO target set. 2,12 The above data are maternal mortality data due to post-partum bleeding. Bleeding factor itself that can cause maternal mortality is recognized by the Ministry of Health since 2010 which continues to increase in 2010 (28%), this is the biggest number of causes of maternal death in addition to other factors such as infections (11%).3

Postpartum hemorrhage is influenced by several factors, such as hypotoniosis due to anesthesia, excess distension, uterine atony, multiparity, thrombophilia, uterine rupture, preeclampsia and many other factors. Preeclampsia itself is a pregnancy disease characterized by

increased

hypertension, in some existing studies, it was suggested that chronic hypertension in pregnancy makes the risk of bleeding large enough during childbirth. 4,5

Preeclampsia is one of the factors causing postpartum hemorrhage where women with preecampsia face increased risk of bleeding, preeclampsia may occur during antenatal, intranatal and postnatal periods. Mothers with severe hypertension in pregnancy ranged from 10%, 3-4% of whom had preeclampsia.9

It has been reported that the incidence of preeclampsia occurs in approximately 2-10% of pregnancies worldwide and is recognized by WHO to estimate the incidence of preeclampsia as a factor of postpartum haemorrhage seven times higher in developing countries, one of them being 2.8% for developing countries.10

Based on the prevalence found in Indonesia, the incidence of preeclampsia in 2014 is about 10% of the causes of maternal mortality in Indonesia according to WHO. a figure big enough compared to developed countries like the United States that is 3.8%. 1,11

Discussion

Sample

Source Indonesia Department of Health 2002

PPH that result in death

SKDI 2012 and Ministry of Health Indonesia

100000

% 0,28

280 0,209

2011

100000

209

WHO 2014The percentage of PPH-related mortality

0,19

100000 190 out of 100.000 nativity

0.3

0.25

0.2

0.15 The percentage of PPH-related mortality out of 100.000 nativity

0.1

The above study showed that the percentage of women dying due to PPH out of 100.000 0.05 were in fact higher in the year of 2002 than they were a decade later. This data was births presented by Indonesian Department of Health and gratefully, there have been improvements over the last decade. Postpartum hemorrhage itself is substantively the leading cause of 0

Indonesia

SKDI 2012 and

Department of

Ministry of Health

Health 2002

Indonesia 2011

WHO 2014

maternal mortality among pregnant women causing 140.000 deaths per year globally. This number corresponds to the one woman dying every 4 minutes throughout the world.

Source

Percentage of PPH that caused MMR from total MMR

Census RI 2010

20,21

Indonesia Ministry of Health 2010 Indonesia Ministry of Health 2011 Indonesia Ministry of Health 2012 Indonesia Ministry of Health 2013

35,1 31,9 30,1 30,3

Percentage of PPH that caused MMR from total MMR 40 35 30 25 20 15

Percentage of PPH that caused

10

MMR from total MMR

T 5 yp 0 al m la fa

Cencus RI Indonesia 2010

Indonesia

Indonesia

Ministry of Ministry of Ministry of

Indonesia

us Ministry of

Health

Health

Health

2010

2011

2012

d Health 2013

he above graphs the rate of maternal mortality b Looking at the data demonstrated given by the Health Ministry of Indonesia, it is rate clear(MMR) that the caused percentage in isIndonesia throughout theofyear of This 2010percentage up till 2013. ofostpartum PPH that hemorrhage caused MMR the highest in the year 2010. wishMatern to show ortality is not caused by high PPH back solely, however infection, hypertension anddeplete previo for that poor itself medical services were then.

However, the numbers gradually bors do three contribute the total number of MMR. It is just is thenot percentage of the mentionethat the next years to consecutively.

Although the depletion significant, it indicates ctors doservices not givethroughout higher rates PPH alone. medical thethan years aredoes improving.

Conclusion The prevalence of PPH in Indonesia is still very high. From this article we know that target MDGs in Indonesia for PPH is still far from grasp. Certain actions are needed to reduce the high numbers, both from the government and medical implementers. As an example, the government can promote training for medical officers to prevent and handle PPH cases. For medical implementers on the other hand, can promote health counseling towards patients, and can provide senior to junior clinicians training so that they can pay more attention towards postpartum hemorrhage cases and to handle them well.

We also recommend that other researchers not to stop in deepening this PPH case, especially in finding ways of prevention or treatment that we have not had time to describe in this article. In addition, we also want clinicians to study the PPH case in order to reduce their prevalence rate and achieve predetermined targets

References:

1. WHO. 2014. WHO recommendations for preventions and treatment of postpartum haemorrhage. Geneva: WHO Library Cataloguing-in-Publication Data.

2. Kementrian Kesehatan Republik Indonesia. 2011. Buku saku Millenium Development Goals (MDG’s) di bidang kesehatan tahun 2011-2015. Biro Perencanaan dan Anggaran Kementrian Kesehatan Republik Indonesia.

3. Kementrian Kesehatan Republik Indonesia. 2010. Rencana strategis kementrian kesehatan tahun 2010-2014. Jakarta.

4. Raras A. 2010. Pengaruh preeklamsia berat pada kehamilan terhadap keluaran maternal dan perinatal di RSUP dr. Kariadi. Universitas Diponegoro.

5. Ahmed R, Dunford J, Mehran R, Robson S, Kunadian V. 2014. Pre-eclampsia and future cardiovascular risk among women: a review. J Am Coll Cardiol. 63(18):18151822.

6. Jekti RP, Suarthana E. Risk factors of post partum haemorrhage in Indonesia. Heal Sci

J

Indones

[Internet].

2011;2(2

Des):66–70.

Available

from:

http://ejournal.litbang.depkes.go.id/index.php/HSJI/article/view/67%5Cnhttp://ejourn al.litbang.depkes.go.id/index.php/HSJI/article/view/67/56.

7.

Ibu K, Sensus SF, Indonesia P. http://ejournal.litbang.depkes.go.id/index.php/kespro/a rticle/download/5102/4311 MATERNAL DEATH IN INDONESIA: FOLLOW-UP STUDY OF THE 2010 INDONESIA POPULATION CENSUS. 2010;(April 2016):1–13.

8. Sheris j. Out Look : Kesehatan ibu dan Bayi Baru Lahir. Edisi Khusus. PATH. Seattle : 2002.

9. Robson, Jason W, Elizabeth S. Patologi pada kehamilan. Jakarta: EGC

10. Osungbade KO, Ige OK. 2011. Public health perspective of preeclampsia in developing countries: implication for health system strengthening. Journal of Pregnancy. 10:1-6.

11. Opitasari C, Andayasari L. 2014. Parity, education level and risk for preeclampsia in selected hospitals in Jakarta. Health Science Indonesia. 5(1): 35-310.

12. Biro Pusat Statistik. 2012. Survey Demografi dan Kesehatan Indonesia (SDKI) 2012.

BPS-BKKBN Depkes RI.

“TDAP VACCINE DURING PREGNANCY AS A PREVENTION FOR PERTUSSIS IN NEONATES” Andy Andrean1, Nurul Anisa1, Rony Wiranto1 1

Faculty of Medicine, Sriwijaya University, Indonesia

Background: Pertussis, a respiratory infection caused by Bordetella pertussis, can affect persons of any age, but it is particularly virulent and life-threatening in neonates. Pertussis has been inadequately controlled compared with other vaccine-preventable diseases, which are associated with the unacceptably high morbidity and mortality observed in young infants.

Neonates are infected by older individuals whose immunity has waned. Despite these successful global pertussis vaccination programs, the disease remains an important public health issue, causing an estimated 63.000 deaths in children <5 years of age. Tdap vaccine during pregnancy could be an effective way to protect neonates until the primary immunization series.

Aim: To indicate the effectiveness of Tdap vaccine in preventing the pertussis in neonates Material and methods: We conducted a systemic review and used some e-journal resources, mainly from NCBI, PubMed, and Elsevier.

Results : Our findings show that maternal vaccine during pregnancy has higher titer antibodies in mothers as well as neonates and no cases of pertussis found on three studies.

Based on animal study (Elahi et al, 2006), maternal immunity provides newly born piglets protection. In the newly born piglets, they received bacteria injection of 5x109 CFU. The groups that received antibodies from their mothers, have slightly more clinical symptoms rather than the control groups. Conclutions: Tdap vaccine during pregnancy shows efectiveness in preventing pertussis by increasing antibodies in neonates.

Authors: Andy Andrean, Nurul Annisa, Rony Wiranto Faculty of Medicine, Sriwijaya University, Indonesia andreanandy12@gmail.com +62812 3965 2335

PREGNANCY EXERCISE IMPACT ON THE INCIDENCE OF PAIN, LEG CRAMPS, AND FATIGUE DURING LABOR IN SURABAYA, INDONESIA Hang Tuah University Annisa Haslidianingsih, Afdini Safitri Dwi M. S., Leny Alimatul H., Nuruddin Dzulkarnain.

Aim To measure the percentagedetermine the impact of pregnancy exercise pregnant woman who do pregnancy exercise aton the incidence of pain, leg cramps and fatigue during labor in Surabaya, Indonesia. Primary Health Center and Home along with the incident of pain, leg cramps, and fatigue during labor.

Background The period of pregnancy and childbirth in women is a very important and unforgettable experience.

Almost all pregnant women experience labor pain. Painless during labor is only happen in a few pregnant women. Moreover , fFatigue during labor will interfering woman's ability to adjust the pain of labor and strength have adequate to contraction for in the second stage of labor, as well as the speed of to adjust the pain and stamina in the second stage of labor as well as disturb maternal and postpartum recovery.

Pregnant women who practice regulardo pregnancyt exercise, especially in the quite regularly during the last three months (third trimesterr), turns out that they, are expected to experience experienced a less painful labor compared to pregnant women who do not practice the exercise.

Material and Methods This study e research design used a cross sectional design with mixedis quantitative and qualitative methodsresearch using cross sectional methodquestionnaire. This present study was carried out on, that is doing by survey with questionnaire tool. Data were collected from 49 breastfededing mothers (primigravida and multigravida) in Surabaya with who had physiological labor (normal labor). All study participants agreed to sign informed consent voluntarily. This research was obtained an ethical clearance No. 9/M/KEPUHT/2017 from the Human Research Ethics Committee of Hang Tuah University.

Results The mean age of study participants From the research conducted from 49 correspondents, unexpectedly there are some differences about do the pregnancy exercise at Primary Health Center and at home; that is 55,1% of correspondent do pregnancy exercise at home while 32,7% at Primary Health Center. Then, these are associated with the percentage of pain during labor which is divided into no pain, mild pain, and severe pain. Along with the incident of leg cramps and fatigue during labor. AroundOf the 49 study participants, 21 were primiparas and 28 were multiparas. The mean age of study participants was 30 years. Around 65.3% of study participants practiced pregnancy exercise at home or joined the program at a Community Health Center; while 34.7% of study participants did not know about the program. All primiparas and multiparas who did not practice pregnancy exercise experienced labor pain; while 31.6% of them experienced leg cramps. Around 75% of primiparas and

42.9% of multiparas who did not practice pregnancy exercise experienced fatigue during labor. On the contrary, a lower percentage of fatigue after delivery was observed among women who practiced pregnancy exercise.

Conclusion Pregnancy exercise has someshowed promising positive influences on the reduction of incidence of pain, leg cramps, and fatigue during laborduring labor. However, many women were not aware of such a program. Therefore, the healthcare workers should promote the program actively to all pregnant women to improve maternal health.

ABSTRACT Vitamin D deficiency have related with with skeletal problems, type 1 diabetes, and schizophrenia, but the prevalence of vitamin D deficiency in U.S. pregnant women is unexplored. We sought to assess vitamin D status of pregnant women and their neonates residing in Pittsburgh by race and season. Serum 25-hydroxyvitamin D (25(OH)D) was used at 4–21 wk gestation and pre delivery in 200 white and 200 black pregnant women from in cord blood of their neonates. Over 90% of women used prenatal vitamins. Women and neonates were classified as vitamin D deficient [25(OH)D ,37.5 nmol/L], insufficient [25(OH)D 37.5–80 nmol/L], or sufficient [25(OH)D . 80 nmol/L]. At delivery, vitamin D deficiency and insufficiency occurred in 29.2% and 54.1% of black women and 45.6% and 46.8% black neonates, respectively. Five percent and 42.1% of white women and 9.7% and 56.4% of white neonates were vitamin D deficient and insufficient, respectively. Results were similar at ,22 wk gestation. After adjustment for prepregnancy BMI and periconceptional multivitamin use, black women had a smaller mean increase in maternal 25(OH)D compared with white women from winter to summer (16.0 6 3.3 nmol/L vs. 23.2 6 3.7 nmol/L) and from spring to summer (13.2 6 3.0 nmol/L vs. 27.6 6 4.7 nmol/L) (P , 0.01).These results suggest that black and white pregnant women and neonates residing in the northern US are at high risk of vitamin D deficiency, even when mothers are compliant with prenatal vitamins.

Higher-dose supplementation is needed to improve maternal and neonatal vitamin D nutriture. J. Nutr.

137: 447–452, 2007.

Breastmilk vs formula milk: a sytematic review Ihsan Fahmi Rofananda1, Imaniar Indraswara2, Veda Septian Cahya Budi3, Fajra Arif Hatman4 1

Pendidikan Dokter, Fakultas Kedokteran, Universitas Airlangga

2

Pendidikan Dokter, Fakultas Kedokteran, Universitas Airlangga

3

Pendidikan Dokter, Fakultas Kedokteran, Universitas Airlangga

4

Pendidikan Dokter, Fakultas Kedokteran, Universitas Airlangga

ABSTRACT Aim: To evaluate the difference of health outcomes in breastfed and formula-fed children.

Background: It is a common knowledge that babies that are fed with breastmilk generally have better intellegence level and growth rate. To check the truth about the statement above, we conducted a systematic review.

Material and Methods: We used PRISMA 2009 checklist as a guideline to write this review, and we used Google Scholar and ScienceDirect search engine to search for studies that met the inclusion criteria. Data from these journal were extracted and presented in original narrative form, including tables and figures. Results: We found three journal articles that met the inclusion criteria. The findings indicate that breastmilk’s content are more suitable to human babies, so it can increase intellegence and growth level. Conclusion: Babies fed with breastmilk have better intellegence level and better growth rate.

Abstract Maternal Caffeine Consumption during Pregnancy Associated with Prenatal and Postnatal Death

Author :

Ahda Basma M*, Chaq El Chaq Zamzam M*, M Ahda Naufal Aflahudin*, R Bagus Yanuar R* *Faculty of Medicine, Universitas Airlangga

Aim- To examine the association between maternal caffeine consumption during pregnancy and the risk of prenatal and postnatal death Background- Caffeine consumption by pregnant women has been associated with an increased risk of spontaneous abortion in some studies. We postulated that maternal caffeine consumption during pregnancy might contribute to the risk of death in prenatal and post natal death.

Methods- This systematic review was conducted to find the association between maternal caffeine consumption with Fetal Death by collecting and critically analyze multiple research studies or papers related to the topic. Finally we use 3 journals in our study.

Result- Mothers that consume coffe more than eight cups has a significant higher risk of stillbirth than the one that consume less, with 300% increasement of risk compared to women who didn't consume any. Even the one that consume four to seven cups a day show a 80% increased risk of stillbirth than women who didn't drank it. Women who consume more than 200 mg of caffeine per day also show an increased number of miscarriage (30.77%) if we compare it to women who didn't consume it(12.5%).

Conclusion- Caffeine consumption is collerated to risk of prenatal and postnatal death. Women during pregnancy should be careful and avoid consuming caffeine excessively.

FREQUENCY OF PRENATAL MORTALITY BY ASPHYXIA Faculty of Medicine, Universitas Airlangga Ahmad Cholifa F, Feriawan Tan, Ayik Rochyatul J., Rayhan Alma S. BACKGROUND Neonatal Mortality Rate is the number of infant deaths the first 28 days of life per 1000 live births. Neonatal Mortality according to WHO (World Health Organization) 2017 in the Asian country as in Myanmar 26.4 per 1000 live births, Thailand 6.7 per 1000 live births, Timor Leste 22.3 per 1000 live births, and Indonesia 27 per 1000 live births. Neonatal mortality rate in Indonesia is still high, when we compared to the SDGs target (Suistainable Development Goals) in 2017 that is 12 per 1000 births life we can conclude the target is so far. Neonatal problems such as birth weight low, asphyxia, and neonatal infection into one cause of death in infants.

Asphyxiaa is one of the causes of mortality and morbidity of neonatal and can make multi organ failure. Asphyxia will cause hypoxia and ischemia in infants, causing damage, mostly occurs in the kidney 50%, central nervous system 28%, cardiovascular system 25%and lung 23% (Radityo, 2012). Perinatal asphyxia is defined as condition of the respiratory gas exchange is not normal with development of acidosis. The case of perinatal asphyxia in neonatal is varies from 1 to 8 in 1000. The indicator to diagnose perinatal asphyxia commonly is the condition of neonatal respiratory system, delayed onset of spontaneous respiration, low apgar score (<6 at 5 min), need for resuscitation and/or ventilation and metabolic acidosis (cord blood PH <7.0 or 7.0 and base deficit >12 mmoL/L). Post natal indicators include neonatal encephalopathy, multi organ failure and abnormal findings on brain imaging (Khattab, 2015).

The Aims of this Study 1.

To know the risk of perinatal asphyxia.

2.

To know the prevention action in order to reduce neonatal mortality caused by perintal asphyxia.

We know that rate of perinatal asphyxia was to high. The number of infant deaths the first 28 days of life per 1000 live births. So there were some prevention strategies to reduce the perinatal asphyxia occurance. One of the most way to prevention is to use Dopamine. Dopamine can reduce the perinatal asphyxia occurance with a suspected lack of oxygen during birth. A lack of oxygen around the time of birth can cause death and long term illness. That was indicated by low Apgar score five minutes after birth and acidic umbilical cord blood (acidocis). So, in short time the infants may need urgent resuscitation, oxygen and supported breathing (assisted ventilation).

Often they have low blood pressure and poor heart function. The drug dopamine stimulates the heart and is used to improve blood flow to the brain and other organs to reduce brain and other organ damage (Hunt and Osborn, 2002).

METHODS

The other ways to reduce the perinatal asphyxia was training of traditional birth attendants. With training the traditional birth attendant, it can improving safe delivery and reducing asphyxia community (Castello and Manandar, 1994).

Based on the neonatal mortality data, we can see now Indonesia still not yet reach the MDGs target, because of that we conduct this study to reduce the neonatal mortality caused by perinatal asphyxia with prevention action.

1.

2.

3.

4.

5.

Counting the number of babies who have asphyxia in 2014-2016.

Compare the datas (2014, 2015, and 2016).

Seeking research on asphyxia prevention.

Compare the advantages with the disadvantages in every asphyxia prevention.

Compare the most effective ways of preventing asphyxia.

DISCUSSION The aim of this review was to know the risk of perinatal asphyxia. Findings for review indicatethat perinatal asphyxia happened because of some risk factors. That were mom’s factor, fetus’sfactor, and labor’s factor. Knowing the risk at first could make us to prepare resuscitation, so ainfants get adequate therapy.

From mom’s factors that were infection (chorioamnionitis), toxemia/eclampsia, maternalchronic disease (hypertension, heart disease, kidney disease, lung disease, and diabetes mellitus). From fetus’ factors that were prematurity, KMK infants, fetal distress, twins, congenital abnormalities, blood group incompatibility, and central nervous system depression by drugs. And from labor’s factors that were polyhydramnios, oligohydramnios, prenatal hemorrhage (placentaprevia, placental solutio), abnormalities, and cord abnormalities (umbilical cord, cord coil) (Manoe and Amir, 2003).

Asphyxia is one of the causes of mortality and morbidity of neonatal. Asphyxia will cause hypoxemia and hypercapnia, accompanied by metabolic acidosis. Hypoxemia may be defined as the “diminished amount of oxygen in the blood supply”, while cerebral ischemia is defined as the “diminished amount of blood perfusing the brain” (Antonucci, et al, 2014).

The other risk mostly occurs in the kidney 50%, central nervous system 28%, cardiovascular system 25%, and lung 23% (Radityo, 2012).

Ischemic hypoxic encephalopathy is common in asphyxiated infants, as well as periventricular-intraventricular bleeding. Ischemic hypoxic consequence is a disorder of intelligence, seizures, psychomotor development disorders and motor abnormalities included in the cerebral palsy. The perinatal consequences of asphyxia on neurology are multifocal or focal cortical necrosis, watershed infarct, selective neuronal necrosis, and marmorata status etc. (Manoe and Amir, 2003).

CONCLUSION Perinatal Asphyxia that causes mortility and morbidity is a major problem in developing countries.

The number of infant deaths the first 28 days of life per 1000 live births. Perinatal asphyxia have some risk, such as hypoxemia and hypercapnia that cause any damage for body.That was damage the kidney 50%, central nervous system 28%, cardiovascular system 25%, and lung 23%. So for preventing increased number of perinatal asphyxia, there were some ways to reduce it. It can use dopamine to improve blood flow to the brain and other organs to reduce brain and other organ damage. And the other ways, with training of traditional birth attendants. These result could provide potentially useful information to reduce the number of infants death cause of perinatal asphyxia.

REFERENCES Antonucci, Roberto, Annalisa Porcella , Maria Dolores Pilloni.2014. ‘Perinatal asphyxia in the term newborn’. Journal of Pediatric and Neonatal Individualized Medicine.vol. 3 n. 2, view 17 October 2017 Costello, Manandhar.1994. ‘Perinatal asphyxia in less developed countries’. The Journal of the British Paediatric Association. 71: F1-F3, view 17 Oktober 2017 Hunt,Rod and David A Osborn.2002. ‘Dopamine for prevention of morbidity and mortality in term newborn infants with suspected perinatal asphyxia’. Cochrane Database of Systematic Review., view 17 Oktober 2017 Khattab, A. A. A. (2015). Tei index in neonatal respiratory distress and perinatal asphyxia.

Egyptian Heart Journal, 67(3), 243–248. https://doi.org/10.1016/j.ehj.2013.12.084

Radityo, A.N., Kosim, M.S dan Muryawan, H. 2012. Asfiksi Neonatorum Sebagai Faktor Risiko Gagal Ginjal Akut. Sari Pediatri, 13(05), 305-310 Hunt,Rod and David A Osborn.2002.

‘Dopamine for prevention of morbidity and mortality in term newborn infants with suspected perinatal asphyxia’. Cochrane Database of Systematic Review., view 17 Oktober 2017

Mane, Vera Muna and Idham Amir.

2003.Gangguan Fungsi Multi Organ pada Bayi Asfiksia Berat.Sari Pediatri. 72-78, view 12 Oktobe 2017 12:43 Radityo, A. N., Kosim, M. S., &amp; Muryawan, H. (2012). Asfiksia Neonatorum Sebagai Faktor Risiko Gagal Ginjal Akut. Sari Pediatri, 13(5), 305–310.

FREQUENCY OF PRENATAL MORTALITY BY ASPHYXIA Ahmad Cholifa F. - Universitas Airlangga

Neonatal Mortality Rate is the number of infant deaths the first 28 days of life per 1000 live births. Asphyxiaa is one of the causes of mortality. Asphyxia will cause several damages for infants.

Perinatal asphyxia is defined as condition of the respiratory gas exchange is not normal with development of acidosis. From mom’s factors that were infection (chorioamnionitis), toxemia/eclampsia,maternalchronic disease (hypertension, heart disease, kidney disease, lung disease, and diabetes mellitus). From fetus’ factors that were prematurity, KMK infants, fetal distress, twins, congenital abnormalities, blood group incompatibility, and central nervous system depression by drugs.

And from labor’s factors that were polyhydramnios, oligohydramnios, prenatal hemorrhage (placentaprevia, placental solutio), abnormalities, and cord abnormalities (umbilical cord, cord coil) (Manoe and Amir, 2003).

Advances in studies of breast milk have indicated that there may be more benefits to be discovered towards the feeding of breast milk for infants. Nevertheless, Parents in developing countries still prefer using formula milk and other breast milk substitute even though exclusive breastfeeding proves to be scientifically better. Therefore, a systematic review was held to find out the background of such preferences. We search for medical journals through a medical search engine (PubMed) using following key words: breast milk, breast milk substitute, developing countries and later found and used 3 of the most relevant journals. We then compared the factors that encourage and discourage breast milk substitution through these journal. Through this method, we gathered information related to our research that is factors regarding the substitution of breast milk including woman employment, advise from family and friends, nutritional value and advertising. Based on this review, we found no defining factors that holds a great effect on the substitution of breast milk and further research needs to be done to define the most probable factors

Postpartum Depression and its Association with Ante Natal Care and Quality of Sleep: A Crosssectional Study Almira Ramadhania, Brian Mendel, Angga Wiratama Lokeswara, Alice Tamara Universitas Indonesia

Background Postpartum depression (PPD) is very common nowadays and related with adverse infant and maternal outcomes. In Indonesia alone, the prevalence of PPD was 2.32% (440/18,937). Sleep disturbance is one of the emerging contributors to PPD. Untreated PPD could effect mother’s health and interfere with her ability to connect with and care for her baby. In theory, Ante Natal Care (ANC) was designed to encompass, not only clinical and laboratory examinations for the mothers, but also the mental health of the mother. None of the materials involve in ANC consist of psychological assessment, and no particular attention is exclusively given for the psychological well-being of the mothers. This means that any potential distress to the mothers may not surface or be expressed clearly by the mothers.

Objective The study has 2 main objectives: 1.

To show the correlation between the current Indonesian ANC with PPD

2.

To show the correlation between PPD and sleep deprivation

Method 107 postnatal women (until 6 months), collected by consecutive sampling method, participated in cross sectional study using Edinburgh Postnatal Depression Scale (EPDS) to predict PPD and Pittsburgh Sleep Quality Index (PSQI) to correlate PPD to maternal sleep quality.

Result Our findings showed no significant correlation between ANC and PPD (p=0.13) while distressing the relationship between PPD and sleep quality (p<0.0001). This indicates that ANC may not be significant to prevent the development of PPD while PPD is shown to have close relation with poor sleep quality.

Conclusion Early assessment of maternal psychological well-being using mental health assessment tool in ANC is important to reduce further complication which might arise from PPD. Keyword: Ante Natal Care, Postpartum Depression, Postnatal, Sleep Quality

ABSTRACT Title: DISSIMILARITIES IN TREATMENT OF IRON-DEFICIENCY AND APLASTIC ANAEMIA DURING PREGNANCY

Anaemia is a condition in which iron deficiency or haemoglobin occurs. Anaemia will be harmful directly to the mother and baby. 15% to 20% of pregnant women in the US have irondeficiency. anemic mothers during pregnancy had a much shorter pregnancy time compared with anemic women who treated with iron supplements. The need for supplements during pregnancy can be overcome with supplements which containing lactoferrin that believed to overcome iron-deficiency. Aplastic anemia is a rare disorder that is innate and potentially lifethreatening, especially in women during pregnancy. Pregnancy is considered a major risk factor for aplastic anemia. Aplastic anaemia tends to lead to mental illness.

Pre-Conference Competition East Asian Medical Students’ Conference 2017

ABSTRACT

Integrated algorithm of postpartum hemorrhage management in developing countries: implication for reaching world’s fifth sustainable developmental goals Andrea Laurentius1 Nathasha Brigitta Selene2 Averina Geffanie Suwana3 Kresanti Dewi Ngadimin4

1

Second Year Medical Student, Universitas Indonesia, (085372724042, laurentiusandrea@gmail.com) 2 Second Year Medical Student, Universitas Indonesia, (082112870839, brigitta.selene@yahoo.com) 3 Second Year Medical Student, Universitas Indonesia, (08111200259, averinasuwana8@gmail.com) 4 Second Year Medical Student, Universitas Indonesia, (08135206000, kresanti.dewi@gmail.com)

Aim The purpose of this study is to evaluate the current preventive measures, diagnostic methods, and AMTSL guidelines from WHO, FIGO, and ICM to produce an integrated algorithm that would best accommodate the low health quality in developing countries, hoping that they could reduce maternal death up to 75%.

Background Postpartum hemorrhage becomes a significant global health issue as reducing 75% of maternal mortality is included in the world’s fifth Sustainable Developmental Goals (SDG). Guidelines provided by WHO, FIGO, and ICM in managing hemorrhage do not always adhere to conditions in some developing countries. Thus, improvement of management with PPH are important challenges

encountered by governments and medical authorities. Possible method involving management of PPH executed optimally in these countries is raised as ultimate question.

Material and Methods Search engine PubMed was used to search for trials that assessed the prevalence, preventive actions, diagnosis, and prophylactic uterotonics of postpartum hemorrhage. Exclusion criteria are studies exceeding the last 15 years, irrelevant topics and data, and non-English journal.

Results Postpartum hemorrhage constitutes for the major causes of global maternal death. Each separated method, comprising preventive measures, early diagnosis, and prophylaxis administration, in managing PPH is combined into a single view of major algorithm would serve as basis in evaluating health sectors’ performance. Initial modification of previous single method could finally conform with the condition of world’s developing countries. In this case, integrated algorithm in PPH management could be applied in many confounding situations of developing countries for future goals in SDG.

Conclusion High prevalence of maternal death in developing countries in the world suggests the inadequacy of maternal health services in hospitals. This condition has encouraged unification of separated and modified PPH management into a single algorithm fundamentally proposed for developing countries, consisting of preventive actions, antenatal care examination for prior diagnosis, and AMTSL drug prophylaxis.

FAIR DISTRIBUTION OF MATERNAL AND NEONATAL CARE TO SUPPRESS MMR IN ALL INDONESIA’S REGION Anindita Rehana, Indah Shofie M., Rafida Sofi K., Nanda Amalia

ABSTRACT

•

Background: Goal number 3 of Sustainable Development Goals proposed by the United Nation is to achieve good health and wellbeing at all ages by the 2030. One step that we can make is to make increasing life expectancy associated with child and maternal mortality. Indonesia is one country that are still unable to reach the target of reduction of MMR, and having unsteady MMR in each province.

With this case, Indonesia’s government needs to make a change and evaluate maternal health of all citizen, even for them who live in rural area.

•

Objective: The study aims to understand the effective policy and health program decisions so that all citizen who live even in rural area gets adequate health services concerning in maternal care.

•

Methods: Census conducted to identify pregnancy-related deaths occurring in all Indonesia’s regions.

This census is conducted with such pattern that is divide the numbers of pregnancy related death with the numbers of all births in that certain region and multiplied by 100.000.

•

Result: The highest risk of maternal death was outside Java Island where health services and health practitioner is not adequate enough. The pattern of maternal causes of death varies between regions.

•

Conclusion: All Medical services in all regions should have decent qualities so that Indonesia has stable variation of MMR in all regions and also declining number of MMR in each year so that Indoesia can achieve SDG-3 by the year 2030.

Breastfeeding Premature Infants Author: 1. Arya F.P. 2. M. Datta T.L 3. M. Zulkifly T. 4. Puguh 0.

Introduction

Discussion

In this systematical review based poster we want to know and compare the results in this two studies about how breastfeeding to premature infants effect the infants and their mothers.

Mothers should be supported to breastfeed before using bottles in the NICU (1).

Introduction and support of lactation and breastfeeding without unjustified delays and restrictions, feeding routines that aim at facilitating frequent breastfeeding and avoidance of bottle-feeding, and efforts for enabling mothers to spend time in the NICU should be regarded as main goals in the care of preterm infants (2).

Material and Mehods The methods in this study is by doing systematical review between the two study

Result Of infants who received human milk at the time of their first oral feeding, 59% received their first oral feeding at breast and 33% of mothers had a specific breastfeeding goal. Mothers who breastfed z 1 direct-breastfeed per day were more likely to have a breastfeeding goal (odds ratio [OR] = 11.13; 95% confidence interval [Cl], 1.43-86.88) and be older (OR = 1.33; 95% Cl, 1.03-1.72). Their infants had more days between the first breastfeed and introduction of a bottle (OR= 1.56; 95% Cl, 1.11-2.17) and had shorter lengths of stay (OR= 0.9; 95% Cl, 0.9-0.97). Mothers were more likely to provide direct-breastfeeding at discharge if they were non-Hispanic (OR= 0.05; 95% Cl,< 0.01-0.60), were primiparous (OR= 0.06; 95% Cl, 0.010.45), had a specific breastfeeding goal (OR = 13.79; 95% Cl, 1.99-95.80), and their infant had a shorter length of stay (OR= 0.94; 95% Cl, 0.90-0.98) (1). One infant, born at 26 weeks, with chronic lung disease treated with additional oxygen at discharge, was fully breastfed and went home at 37 weeks (2).

Conclusion From the two studies that we reviewed both have a conclusion that it's essential to give the premature infants breastfeeding.

References 1. Briere C, McGrath J, Cong X, Brownell E, Cusson R. Direct-Breastfeeding Premature Infants in the Neonatal Intensive Care Unit.

Journal of Human Lactation. 2015;31(3):386392.

2. 2. Nyqvist K. Lack of Knowledge Persists about Early Breastfeeding Competence in Preterm Infants. Journal of Human Lactation.

2013;29(3):296-299.

Title: Breastfeeding premature infants Name of University and Authors: Universitas Airlangga: Arya Fadhilah Pradana, Muhammad Daffa Tandry Lala, Muhammad Zulkiffly Tasman, and Puguh Oktavian.

Aim: To give information on how important it is to breastfeeding premature infants.

Material and Methods: The methods in this study is by doing systematical review between the two study.

Background: Why we brought this topic is because we think it was important to share the knowledge on the importance of breastfeeding premature infants which is still lacking.

Result: Of infants who received human milk at the time of their first oral feeding, 59% received their first oral feeding at breast and 33% of mothers had a specific breastfeeding goal. Mothers who breastfed ≥ 1 direct-breastfeed per day were more likely to have a breastfeeding goal (odds ratio [OR] = 11.13; 95% confidence interval [CI], 1.43-86.88) and be older (OR = 1.33; 95% CI, 1.03-1.72). Their infants had more days between the first breastfeed and introduction of a bottle (OR = 1.56; 95% CI, 1.11-2.17) and had shorter lengths of stay (OR = 0.9; 95% CI, 0.9-0.97). Mothers were more likely to provide direct-breastfeeding at discharge if they were non-Hispanic (OR = 0.05; 95% CI, < 0.01-0.60), were primiparous (OR = 0.06; 95% CI, 0.01-0.45), had a specific breastfeeding goal (OR = 13.79; 95% CI, 1.99-95.80), and their infant had a shorter length of stay (OR = 0.94; 95% CI, 0.90-0.98) (1). One infant, born at 26 weeks, with chronic lung disease treated with additional oxygen at discharge, was fully breastfed and went home at 37 weeks (2).

Conclusion: From the two studies that we reviewed both have a conclusion that it’s essential to give the premature infants breastfeeding.

ABSTRACT

Neonatal Morbidity: The Risk and Developing Awareness Way: Systematic Review Faculty of Medicine Universitas Airlangga Assyadilla Kirana, Diska Hanifah, Sharifa Audi, Shinta Lungit

Aim This review was conducted to study the risk of neonatal births occured and to increase people’s awareness level.

Background In the past few years, Neonatal Morbidity level increased in several dovelopment countries. It hits 36 per 1000 births. Also the importance of seeking care from health worker will be increasing the community awareness about neonatal morbidity, decreasing effects of death after birth by the importance of seeking care from trained personnel, and the availability of services for these conditions.

Material and Methods This review is based on the journal’s online data. Analysis articles using search engines: oxford journals and google scholar. Also with the inclusive category: cohort studies and the article from the past 20 years about neonatal morbidity.

Results Some countries in the world have lower rates of neonatal mortality caused by polio, neonatal tetanus, and other vaccine preventable diseases. The decrease of neonatal mortality was caused by vaccination of the various diseases.

Based on what we found in journal, it shows that there are no major difference between male and female neonates. In general, symphtons of morbidity include fever, breathing diffuculty and had other complications which include constipation, suppression of urine, blue extremities.

Conclusion It is true that neonatal birth causing several health issues for infants, such as respiratory morbidities, temperature instability, hypoglycaemia, spesi, huperbilirubinaemia, necrotizing enterocolitis, neurological morbidities, and even neonatal and infant mortality. But now they are preventable by vaccination and those risks can be decreased. Besides people’s awareness is increased because of health care providers and professional personnel.

Maternity Waiting Homes ( MWHs ) : A potential solution as an intervention in the rates of neonatal and maternal mortality in rural area AMSA Chapter Indonesia Bethaniel Roy Matthew, Sergio Paipinan, Alfiona Jesica Lekenila

Faculty Of Medicine Christian University Of Indonesia INTRODUCTION

METHOD

Each year more than half a million woman were die related to pregnancy and childbirth . Almost 4 million newborns die within 28 days of birth . The world bank data showed that Indonesia in 2015 had 6400 cases and it brought Indonesia on top of maternal mortality rates in Asia region. At the same time in 2016 Indonesia had 67,862 cases on neonatal deaths. A limited access to the nearest health care service is the main cause of the high rates of maternal and neonatal death in rural area.

Maternity Waiting Homes ( MWHs ) is a great potential solution to answer this challenge. Maternity waiting home (MWHs ) is a accommodation located near a health facility where women can stay towards the end of pregnancy or after birth to enable timely access to essential childbirth care or care for complications which provide a emergency obstetric care ( WHO )

RESULTS The diagram shows causes of maternal and child death.

Hemorrhage, hypertension , sepsis, abortion, and pre existing medical illness

Table 2.Number of deaths from 28th Week of Pregnancy to Age Five Years 2000 & 2015

A systematic literature review was conducted to get a suitable journal for this scientific poster. The use of the following databases of the medical literature such as ; PubMed, WHO document, BioMed Central and search engine such as Google Scholar was conducted.

After some journals and articles with keyword ( Maternal and neonatal health ) were screened , we decided to fully read 8 studies which related to our topic to obtain the result. Inclusion and exclusion criteria were included. The inclusion criteria was journal or literature related to maternal and neonatal health from 2009-2016 and the other were included in exclusion criteria.

DISCUSSION Table 2 shows number of mortality from 28th weeks of pregnancy to age five years which still highh.Studies by Say et al. in 2014 ( Figure1.1 ) showed the most dangerous cause is hemorrhage.Studies which were conducted by J Kelly , et al( Table 1 )in Ethiopia showed that MWHs had contributed to improved pregnancy outcomes. The studies of 24,148 deliveries included 17,343 admitted directly and 6,805 via MWH reported a MMR of 89.9 per 100,000 live births for users of MWHs, and 1,333.1 per 100,000 live births for non-users.From this studies we can conclude that a good accessibility to get a primary care in obstetric and newborn care and a Professional practitioner are the keys to increase the rate of live birth and maternal health .Data above shows that MWH which was implemented in Ethiopia is effective enough in reducing MMR While increasing numbers of women are accessing prenatal care,fewer of them utilize facilities for delivery. It is therefore plausible that having a MWHlocated near the clinic could increase access for those women who pursue prenatal care but do not deliver at the clinic due to the barrier of distance

CONCLUSION Table 1 shows delivery factors and outcomes for women admitted via maternity waiting home and for them who don’t. In 2008 there are 6 maternal deaths/100.000 live births for women who use MWH and 187 maternal deaths/100.000 for women who don’t use MWH

Maternal and neonatal mortality rates can be decreased gradually by implementing MWHs in rural area . This program is really suitable for developing country which the rates of MMR is still high. Also MWHs can be a potential solution for rural area which accessibility to skilled care is limited. We realize that there are some aspects which could be developed in this scientific poster. We encourage the other authors to do more research about maternity waiting homes in preventing maternal and neonatal death especially in rural area.

Referrences 1. WHO Recommendations on Health Promotion Interventions For Maternal and Newborn Health. (2015). 1st ed. Geneva: WHO Library Cataloguing-in-Publication Data, pp.7-26.

2. Black, R., Laxminarayan, R., Temmerman, M., Walker, N. and Bustreo, F. (2016). Reproductive, maternal, newborn, and child health. 3rd ed. Washington (D.C.): World Bank, pp.1-13.

3. Lonkhuijzen, L., Stekelenburg, J. and Roosmalen, J. (2012). Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries. Cochrane Pregnancy and Childbirth Group, [online] pp.1-21. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19588403 [Accessed 20 Oct. 2017].

4. Lori, J., Wadsworth, A., Munro, M. and Rominski, S. (2013). Promoting access: The use of maternity waiting homes to achieve safe motherhood. Midwifery, 29(10), pp.1095-1102.

5. Satti H, McLaughlin MM, Seung KJ. The role ofmaternity waiting homes as part of a comprehensivematernal mortality reduction strategy in Lesotho.PIH Reports 2013;1(1).

6. Kelly, J., Kohls, E., Poovan, P., Schiffer, R., Redito, A., Winter, H. and MacArthur, C. (2010). The role of a maternity waiting area (MWA) in reducing maternal mortality and stillbirths in high-risk women in rural Ethiopia. BJOG: An International Journal of Obstetrics & Gynaecology, 117(11), pp.1377-1383.

7. Options Consultancy Services Ltd, Partnership Management, Evaluation & Learning (PMEL). (2015). Literature Review of Maternity Waiting Homes. London: PMEL. 8. Morrow, M., Dayal, P., Zhen, J., Luke, G., Gopalakrishnan, A. and Ndwala, S. (2017). Reducing maternal, newborn and child deaths in the Asia Pacific strategies that work. [online] (1), pp.1-28. Available at: http://www.comminit.com/communicating_children/content/reducing-maternal-newborn-and-child-deathsasia-pacific-strategies-work [Accessed 20 Oct. 2017].

Maternity Waiting Homes ( MWHs ): A Potential Solution as An Interventions In The Rates of Neonatal and Maternal Mortality In Rural Area Bethaniel Roy Matthew, Sergio Paipinan, Alfiona Jesica Lekenila AMSA-Universitas Kristen Indonesia

Background : Each year more than half a million woman were die related to pregnancy and childbirth.

Almost 4 million newborns die within 28 days of birth . The world bank data showed Indonesia in 2015 had 6400 cases and it brought Indonesia on top of maternal mortality rates in Asia region. At the same time in 2016 Indonesia had 67,862 cases on neonatal deaths. An accessibility to the nearest health care service is the main cause of the high rates of maternal and neonatal death in rural area. Maternity Waiting Homes ( MWHs ) is a great potential solution to answer this challenge. Maternity waiting home (MWH ) is a accommodation located near a health facility where women can stay towards the end of pregnancy or after birth to enable timely access to essential childbirth care or care for complications which provide a emergency obstetric care ( WHO ) Method : A literature systematic review was conducted to get a suitable journal for this scientific posterThe use of the following databases of the medical literature such as ; PubMed, NCBI, WHO document, Google Scholar, and BioMed Central was conducted. Inclusion and exclusion criteria were included. The inclusion criteria was journal or literature related to maternal and neonatal health from 2009-2016 and the others were included in exclusion criteria.

Result : A number of studies conducted by J Kelly , et al in Ethiopia showed that MWHs had contributed to improved pregnancy outcomes. The studies of 24,148 deliveries included 17,343 admitted directly and 6,805 via MWH reported a MMR of 89.9 per 100,000 live births for users of MWHs, and 1,333.1 per 100,000 live births for non-users.

Conclusion : Maternal and neonatal mortality rates can be decreased gradually by implementing MWHs in rural area . This program is really suitable for developing country which the rates of MMR is still high. Also MWHs can be a potential solution for rural area which accessibility to skilled care is limited.

Keyword : Maternal and neonatal health, Maternity Waiting Homes (MWHs), Maternal and neonatal mortality rates Contact Details Regional Chairperson AMSA-Indonesia Name : Elvira Lesmana Email : rcindonesia@amsa-international.org Phone : +6285811240637

The Importance of Education and Income Rate as Factors of Maternal Health Amongs Mothers in Cawang, East Jakarta Cindy Priskila Panjaitan, Deta Hamida, Irma Rebina R. Lumbantoruan, Prabu Suja Samhari AMSA - Universitas Kristen Indonesia

Introduction Indonesia is a developing country which has high rate of poverty, low education level and medical care. Based on data from Badan Pusat Statistik 2015 poverty rate in Indonesia are 255,416,686 people (11% of total population). In this research we focused on data about education, annual income, and body mass index (BMI) in Cawang, East Jakarta. Lack of maternal education and low or unstable income may cause maternal ignorance about their fetal care by consuming balance diet and controlling their fetal health. For that reason, in this research poster, education and income rate are the main factors to achieve maternal health.

By random sampling method in 183 famili- es consist of 22 pregnant women, 138 breastfeeding mothers, and 23 couples of reproductive age. Data which has been taken are income, education, and body mass index. We are looking for the relationship between these four factors

Material & Methods The metode of this study is crosssectional with random sampling. We used questionnaires as the instrument and the data obtained the meassurement of anthopometry.

In addition, to have a good quality job, it requires a higher education. However, low education will have less job opportunities, which means the lower education they have, the harder for them to find stable income. Further more, with lower income leads to low quality of life which may cause malnutrition. A proposional nutrition is important for all family members, especially for pregnant women.

Pregnant woman needs a balance nutrition to support maternal and fetal health.

Discussion

with the health of pregnant women.

Conclusion

Education and income rate affect the nutrition of pregnant women.

There are approximately 80% of families that have income above 2 million. Thus expected, family income can fulfill the needs of mothers when pregnant.

From the research found that there are 30.7% of families in Cawang who did not complete 12 years of education.

The result of BMI showed that 58% of women were normal.

Result

References 1. Afifah T, Tejyanti T, Saptarini I, Rizkianti A, Usman Y, Senewe F. Maternal Death in Indonesia: Follow-Up Study of The 2010 Indonesia Population Census. 2016;7(1). Available from: http:/ejournal.litbang.depkes.go.id/index.php/kespro/article/views/5102/4311 2. Rohy A, Retnaningsih L, Fatimah F. Hubungan Status Gizi Ibu dengan Berat dan Panjang Bayi Baru Lahir di Rumah Bersalin Widuri Yogyakarta: Jurnal Keperawatan Respati Yogyakarta. 2017;4(1);133-137. Available from : http//nursingjurnal.respati.ac. id/index.php/JKRY/index.

3. Marsedi G, Widajanti L, Aruben R. Hubungan Sosial Eknomi dan Asupan Zat Gizi dengan Kejadian Kurang energi Kronik (KEK) pada Ibu Hamil di Wilayah Puskesmas SEI Jang Kecamatan Bukit Bestari Kota Tanjung Pinang 2016: Jurnal Kesehatan Masya rakat. 2017;5(3);ISSSN: 2356-3346. Available from : http://ejournal-sl.undip.ac.id/index. php/jkm 4. Badan Pusat Statistik Indonesia.Statistik Indonesia 2015. Jakarta: 2016 Januari.

The Important of Education and Income Rate as Factors of Maternal Health Amongs Mothers in Cawang, East Jakarta Christian University of Indonesia.

Cindy Priskila Panjaitan, Deta Hamida, Irma Lumbantoruan, Prabu Suja

Abstract Aim : To asses whether the level of education and families income affect the health of maternal pregnancy.

Material and Methods : In this trial, we found 183 families in Cawang who have maternal pregnancy. The method of this study is cross-sectional with random sampling test. We used questionnaries as the instrument and the data obtained consist of anthropometry.

Result : The income rate, education and body mass index was the variabel that we got. There’s 80% of the families whose income level above 2 million rupiahs. In hope the families’s income level may fulfill the maternal pregnancy needs. The persentage of education level in cawang was 30,7% who did not attend school until high school. The body mass index of mothers are found 25% which including BMI is not ideal.

Conclusion : Education and income rate are significant factors to maternal nutrition.

Contact Details Regional Chairperson AMSA-Indonesia Name : Elvira Lesmana Email : rcindonesia@amsa-international.org Phone : +6285811240637

REVOLUTIONARY MALARIA IN PREGNANCY THERAPY USING ALLICIN FROM GARLIC EXTRACT(ALLIUMSATIVUM): BIOMOLECULAR STUDIES USING IN SILICO

Fakhia Iffa Tunnisa1, Dedy Budi Kurniawan1, Mokhamad Fahmi Rizki S1, Editya Fukata1 University Of Brawijaya

Abstract

Malaria is an endemic disease that can lead to death. Malaria in pregnancy is a major contributor to maternal and neonatal morbidity and mortality. The malarial control and management can be threatened by antimalarial drug resistance and adverse effect, in this way renewable therapies are needed to overcome this disease. The surface of sporozoites has a major protein called circumsporozoite protein (CSP), which is played by cysteine proteases during invasion process of host cells. Inhibition of cysteine protease will prevent invasion of host cells. Garlic extract contains allicin which has the potential to be a malarial disease therapy. Th aim of this study is to know about effectifity allicin toward as malaria in pregnancy. The author uses 2 methods of systematical review and in silico methods. A study of the systematical review was conducted to prove the consistency of the results of in silico. The searching of literature study used the three major search engines: NCBI, Sciencedirect, Clinical key with the keywords "allicin", "garlic", "plasmodium falciparum", "antimalaria", "cysteine protease" in vivo ", in vitro". research published in 5 years (2012-2017) and English literature. The method in silico uses cysteine protease sequences obtained from uniprot and pubchem data. The results of the insilico method show that allicin is able to bind to the active site of protein cysteine protease enzyme that plays a role in host cell invasion The active side of the protein enzyme cysteine protease binding to allicin is alanine 206 with a bond strength of 3.7 kcal/mol as the highest value and -3.3 Kcal/mol as the lowest value. Sporozoit treated with allicin 10μM, 25μM, and 50 μM dosage for 10 minute, allicin was diluted 12-times, and then diluted sporozoite and allicin were added to the cell. Allicin can be given by oral administration because it has a good amount of biovability and allicin has high quantity of log p, hance it become lipophilic property. Allicin is also safe for pregnant women proven by positive effect on birth weight and higher values of internal organ of animal model.

Keyword : Allicin, Malaria pregnancy, cystein protease, In Silico

Reduce Ultraviolet Radiation: Low er The Risk of Preterm Birth and Hypertension Pregnancy (Dian Anggraini P. M., Cindy Aprilia E. P., Pratista Oktafia, David Setyo B. ) 2017 - Faculty of Medicine, Universitas Airlangga https://pngtree.com/element/down?id=MTExNTY4OA==&type=1 access at 19 October 2017

INTRODUCTION Determined by wavelength, solar ultraviolet (UV) is made up of three components, these are UVA, UVB, and UVC. UVA wavelength between 315-400 nm and UVB between 290-315 nm. UV exposure on the ground is determined by solar zenith angle which is determined by calendar date as well as factors such as altitude, the degree of cloud cover, and proximity to the coast.1 UV radiation are related with season and vitamin D. An association between season and preterm birth, low birth weight ; immune, infectious, vitamin D and hormonal pathways implicated.2 Thayer,Z.M.3 evaluated whether differences in UV light availability contribute to racial disparities in adverse birth outcomes in the United States. Futhermore, sunlight intensity is correlated with pregnancy hypertension.4 We hypothesize that UV radiation could influence maternal and perinatal outcomes especially the risk of preterm birth and pregnancy hypertension.

Figure 1 : Relationships between income inequality, as indexed by a higher Gini coefficient, and disparities in A) low birth weight (LBW) and B) preterm birth (PTB) across tertiles of the ultraviolet (UV) index spectrum in the United States.3 Alger et al.4 stated that higher 1st trisemester and lower 3rd trisemeter solar radiation were correlated with risk of pregnancy hypertension. Pregnancy hypertension was strongly and positively correlated with solar radiation at 1 month after conception. 4 But, solar radiation intensity at 7 months after conception was inversely correlated with pregnancy hypertension rates.4

METHOD

Futhermore, hypertension is affects approximately 10% of pregnancies and it found that that women with pregnancy hypertension complications have an increased risk for developing cardiovascular disease in later life.5

We included studies that examined a relationship between pregnancy outcome and UV radiation exposure, included effect beyween pregnancy and sunlight intensity.

We searched the journal from ELSEVIER (2017), American Journal of Obstetrics and Gynecology (AJOG) (2010) , BMJ (2010), and also American Journal of Epidemiology (AJE) (2014). Almost all of the journal was accessed on 17 October 2017.

This systematic review was developed based on online journal that had a good validity and we only use the last ten years journals for making actual scientific poster.

A narrative synthesis of the data is employed in this scientific poster with a discussion due to lack of information and knowledge.

Included studies are observational enviromental study and cohort prospective research so risk of bias can be reduced. And also all of the journal took the sample randomly so the result can be generalized to all of populations.

RESULT

Figure 2 : A, Mean pregnancy hypertension rate (month of conception cohorts) vs mean solar radiation 1 month after conception. B, Mean pregnancy hypertension rate (month of conception cohorts) vs mean solar radiation 7 months after conception.4

DISCUSSION This review is focusing on the association between ultraviolet radiation and preterm birth, pregnancy hypertension.

The way to reduce the side effect of UV radiation such as using the hats or umbrella and clothing that cover whole body, using black eyeglasses or protective eyewear their lensa able to absorb the UV light, and also to absorb the UV light and also preventing to have an outdoor activity around the middle of the day.6

CONCLUSION Thayer,Z.M. appraised the assosiation between UV radiation and Preterm

Ultraviolet radiation is associated with preterm birth and pregnancy hypertension. There was a positive relationship between UV radiation and absolute rates of Low Birth Weight (LBW) and Preterm Birth (PTB). Also there was corre-

Birth (PTB) rates using a similar methodology to its Low Birth Weight (LBW)

lation between higher 1st trisemester and lower 3rd trisemeter solar radiation

3

comparison in United States. It found that there was a positive relationship between UV radiation and absolute rates of LBW and PTB. States with greater income inequality had imbalance in birth outcomes across the UV radiation.3 REFERENCES 1.Cherrie, M.P.C., Wheeler, B.W., White, M.P., Sarran, C.E., Osborne, N.J., 2015. Coastal climate is associated with elevated solar irradiance and higher 25(OH)D level. Environ

2.Beltran, A.J., Wu, J., Laurent, O., 2013. Associations of meteorology with adverse pregnancy outcomes: a systematic review of preeclampsia, preterm birth and birth weight. Int. J. Environ. Res. Public Health 11

Abstract Aim : To lower the risk of preterm birth and hypertension pregnancy by reducing ultraviolet radiation.

Background : Hypertension pregnancy is serious problem cause of morbidity and mortality for mother and infant. Solar ultraviolet is made up of three component, these are UVA, UVB, UVC that could influence maternal and perinatal outcome, especially the risk of of preterm birth and hypertension pregnancy.

Material and method : We conducted a systematical review of ELSEVIER, American Journal, BMJ, and American Journal of Epidemology about UV, pregnancy, and hypertension.

Result and Discussion : Ultraviolet radiation have good effect to solve problem hypertension pregnancy at 1 month after conception.

Conclusion : Reduce ultraviolet radiation could lower the risk of preterm birth and hypertension pregnancy.

Betamethasone Effects on The Baby’s Lungs with Indications of Premature Birth Dopang Andrianto, Anggi Christian Marbun, Dewa Ayu C.P. Puri, Khalida Sheiks M. AMSA-Universitas Kristen Indonesia

A. Abstract The high rate of infant mortality in developing countries is one of the concern in health problem. One of the causes of infant death is respiratory distress syndrome. In this study, the methodology used in there is a randomized clinical trial with a comparison between the betamethasone administration with placebo. Clinical outcomes were obtained on lung cell maturation rates in preterm infants 34 weeks 0 to 36 weeks 5 days.

Keyword : Betamethason, Premature, Lung B. Background The mortality rate of Infant death in developing countries is high, including Indonesia.

This is caused by improper management and Treatment. In some cases that cause high infant mortality rates are respiratory distress syndrome, intraventricular hemmorage, necrotizing enterocollitis, and various types of infectious diseases.[1] Respiratory distress syndrome is breathing disorder cause by Underdeveloped lung’s cell in premature birth, where the bronchus is not well developed, also the lack of surfactant to keep the lung from collapsing.[2] C. Methodology The methodology used to write this scientific poster is using a systematic review from the results of research that has been done before. The study was conducted in a randomized clinical trial.[2] D. Result

Table 1. Primary Outcome.[2]

Table 2. Secondary Outcome.[2]

E. Discussion

Intramuscular injection of betamethasone in singleton pregnant women diagnosed with a birth premature in 34 weeks 0 days to 35 weeks 5 days are clinically proven to help the maturation lung cell in premature infants is based on primary outcome. According to schimmer et al, betamethasone will improve the bronchial smooth muscle response toward catecholamines.[2] The National Institutes of Health and The American College of Obstetricians and Gynecologists recommends administration of betamethasone 2 times with a dose of 12 mg with a 24 hours Interval, but the injection should be observed because if the excessive injection will have side-effects that interfere with the maturation of the adrenal glands and disturbing the infant weight.[3][4] F. Conclusion The use of betamethasone in singleton pregnant women with high risk of premature birth at week 34 weeks 0 days to 36 weeks 5 days helps the maturation of lung cells in premature infants. However, for the benefits gained from betametason in the premature infants at childhood regarding the likelihood of a lung distress further research is needed.

G. Bibliography 1. Joint Committe on Reducing Maternal and Neonatal Mortality in Indonesia; Development, Security, and cooperation; Policy and Global Affairs; National Research Council; Indonesia Academy of Sciences.

Reducing Maternal and Neonatal Mortality in Indonesia : Saving Lives, Saving The Future. Washington (DC) : National Academies Press (US); 2013 Dec 26. 3, Maternal, Fetal, and Neonatal Mortality.

2.

Bannerman CG, Thom EA, Blackwell SC, Tita ATN, Reddy UM, Saade GR, et al. Antenatal betamethasone for women at risk for late preterm delivery. N Engl J Med. 2016 April;374(14):1311-20.

3.

Salim R, Suleiman A, Colodner R, Nachum Z, Goldstein LH, Shalev E. Measurement of betamethasone concentration in maternal serum treated for fetal lung maturity; is it feasible. Reproductive Biology and Endocrinology. 2016:14(7):1-5.

4.

Schimmer BP, Parker KL. Adrenocorticotropic Hormone; Adrenocortical steroids and their synthetic analogs; inhibitors of the synthesis and actions of adrenocortical hormones. In: Brunton LL, Lazo JS, Parker KL, eds. Goodman & Gilmans’s the Pharmacological Basis of Therapeutics. 11th. New York:McGraw-Hill; 2006. p. 1587-612.

The Overview of Caesarian Section Indication in Makassar as an Outlook of Fetomaternal health in Indonesia Fadhilah Putri Wulandari1, Ilham Akbar Rahman1, Iin Fadhilah Utami1, Zakirunallah Karunia1 1

Faculty of Medicine Hasanuddin University (AMSA-Unhas)

Background:

The mortality and morbidity rate of mothers and infants in Indonesia is still high. Caesarean section is done as a secondary indication for some complicated cases. Only 25% of all hospital delivers in Indonesia undergoing this surgical intervention.

Aim: The aim of the study was to find the correlation of caesarian section indications and conditions of maternal and the newborn.

Material and Methods: A cross-sectional study was conducted among all mothers and newborn at one of the main referred delivers hospital (Fatimah maternity hospital) in Makassar as one capital city in Indonesia from January 1st to June 30th 2016. Samples were collected and analyzed using SPSS.

Result: In this study, 119 babies were evaluated from mothers who underwent caesarian section.

Indications of section caesarian were mostly due to CS history 30 (25,4%). Patients were referred from GP 1 (0.8%), Puskesmas 81 (68.1%), Clinic 15 (12.6%), Puskesmas Pembantu 2 (1.7%), Maternity hospital 7 (5.9%) and General hospital 13 (10.9%). There were a significant difference between newborn condition and patients refer (p<0.05). The level of mother’s education were varied from SD (elementary school)-S1(undergraduated) and there was significant difference in newborn condition and level of patient’s education (p<0.05). The level of newborn weight were classified as <2500 g 26 (21.8%) and normal weight (2500 g4000 g) 93 (78.2%). We also found the significant difference between the level of newborn condition and newborn weight (p<0.05). But there is no significant relationship existed between the

newborn condition and indication of CS. The newborn condition was evaluated based on APGAR score.

Conclusions: The newborn condition of caesarian section was highly correlated with level of mother’s education, newborn weight, and patient’s refer. Therefore, by this data we can show to the government as those contributing factors should be evaluated to improve the facilitation to decrease the mortality and morbidity of maternal and child as the way to improve fetomaternal health quality in Indonesia.

HAVE YOU HEARD, MOM? A Systematic Review about Mass Media Effect on Promoting Mternal Health

Authors : Fernando Mario Regina Rachel Gunawan Vincent Lau Vincentius Dennis Prabaniarga

YOGYAKARTA 2017

I.

Background

The third SDGs (Sustainable Development Goals) is to reduce the maternal mortality by less than 70 per 100,000 live births and the global neonatal mortality to be less than 12 deaths per 1000 live births by 2030. To achieve SDGs, Indonesian government has implemented Antenatal Care which shows high participation number according to Profil Kesehatan Indonesia 2015, but even so why the maternal mortality in Indonesia is still above 300 per 100.000 live births? We suggest loopholes in the quality of the maternal health service, especially in how to educate patient.

In developing countries, maternal education is only shared by doctor and by oral health education, not by other means such as mass media. One of the the way is through Mass media, and to know how effective mass media could be, we decided to do systematical review about the impact of Mass Media to mother utilization of skilled Healthcare worker help for delivery, exclusive breastfeeding and Antenatal Care (ANC) participation

II. Material and Method

We use systematic review of cross sectional studies from databases : PubMed, PMC, Sciencedirect, etc, according to the inclusion and exclusion criterias we had determined. The keyword used are “Mass Media” AND “Maternal Health”, and critical analyzed with CEBMa checklist for cross sectional study and for statistical analysis we used MedCalc . The writing structure are based from combination of PRISMA and PCC EAMSC Guideline.

III. Result

We screened about 278 records and finaly odo 3 meta-analysis according to the factors affecting maternal health with 6 last records. The overall OR of exclusive breastfeeding is 2,34 ( 95% CI 1.984 to 2.768, p <0,05 ), OR for ANC Participation is oodd ratio is 2,78 ( 95% CI 2.076 to 3.718, p <0,001 ), and overall Skilled Healthworker Help for delivery odd ratio is 3.46 ( 95% CI 2.968 to 4.025, p <0,001 ). The result proves that mass media has significant positive effect to the factor of maternal health.

IV. Conlusion Mass media has significant positive effect on exclusive breastfeeding, skilled healthworker help for delivery, and ANC participation. It shows that mass media holds vast potential for increasing the maternal health through education.

Empowerment the Pregnant Woman with Prenatal Class and Solving the Problem on

Maternal and Neonatal Health Cindy Zerlina Artanti, Destasari Tri Hartanti, Hazura,Grace Manuela Nurhadi Introduction Prenatal classes activities facilitate pregnant women about P4K (Birt h Planning and Prevention of Complications). Prenatal class is a means to learn together about the health of the pregnant women, in face-to-fa ce form in a group.

The prenatal class‛ objectives are to improve the knowledge and skills of mothers about prenatal care so that the mother and fetus are healt hy (This prenatal class discuss more about the basis before and aft er pregnant, like defining about pregnancy, signs of pregnancy, complain ts during pregnancy, physical and emotional changes in pregnancy, how to maintain a healthy mother and the intelligence of a fetus, things th at need to be avoided during pregnancy, the myth/taboo, and the preparati on for childbirth, comfortable labor, healthy mothers and babies, disea se and complications of pregnancy prevention, and how to reach optim al growth and development. Indicators of output expected from Prenat al Class program is an increase in coverages of K1, K4, precentage of moth er or family with birth planning by health personnel, percentage of postpartum visits coverage, percentage of neonatal visits coverage.

*

Conclusion

Materials and Methods This study applied analytical observational study with cross sectional approach. The number of samples taken was as many as 30 mothers, using simple random sampling.

Analysis of data was carried out using cordinal wilcoxon sign rank test. Datas were obtained from interview and questionnaire.

The materials : ❖ P4K Material ✓ Due-date of labor ✓ Labor attendant ✓ Birth Place ✓ Transportation ✓ Birth Companion ✓ Potential Blood Donors ✓ The need for labor ✓ Labor savings ✓ Post-labor contraception

To achieve Indonesia as one of SGD’s country, Prenatal class with P4K System is one of the best solution to achieve it. By a good plan before childbirth and prevention against complication, these things could determine the successful of obstetric maternal and neonatal emergency, which can reduce maternal and infant mortality rate.

❖ Media Maternal and Child Health Book ❖ Prenatal Class Flip Chart

Discussion

The result showed there was an influence of prenatal

References

class to the P4K practice ( p=0,000). Statistical analysis showed differences in the practice of P4K, before, and after prenatal class was given. Lack of childbirth planning and prevention of complications in pregnant women would have the impact on pregnant woman and fetus. Through the Program of Birth Planning and Prevention of Complications (P4K) with a

Christiana, Ari. 2015. Effect of Class Opt Against Genesis Pregnancy Complications Labor in Puskesmas Bumiaji Batu. Thesis. Airlangga University.

Ministry of Health. 2011. Guidelines for Pregnant Women Class. D irektorat General of Health Maternal and Child Development Ministry of Health of the Republic of Indonesia. Jakarta

Dyah.P. 2012. Effect of Pregnancy Class Knowledge and Attitudes towards Women in Pregnancy and Childbirth in Regional Health Center Gurah Kediri., Surakarta. Thesis, University of March. Retrieved from: http://pasca.uns.ac. id/?p=2812 > (Citation March 12, 2016)

MOH. 2012. General Guidelines for Pregnant Women Class Management. Jakarta. MOH

Hidayat, Alimul. 20 09. Nursing Research Methods and Data Analysis Techniques, Jakarta: Salemba Medika

sticker that is sticked to the houses of pregnant woman, then every pregnant woman will be registered, recorded and monitored appropriately. So that the process of childbirth to puerperal phase including the referral can be run safely. Prenatal classes is also facilitated by blood tests for pregnant woman and families. Blood type is very important to know the compatibility between blood donors and recipients of blood. This can prevent the risk of complication during pregnancy, childbirth, or postpartum, helping pregnant woman in an emergency and taking important decisions.

Handriani, Beautiful. 2015. Effect of Emergency Obstetric Referral Process Against Maternal Mortality in hospitals Sidoarjo. T esis. Airlangga University Surabaya .

Hidayat, Alimul. Nursing Research 2009 Scientific and Technical Writing. Jakarta: EGC Hidayat, Alimul. 20 09. Nursing Research Methods Medika and Data Analysis Techniques, Jakarta: Salemba Ministry of Health. 2013. Maternal Health Care in Primary Healthcare Facilities and Referral. Jakarta: Ministry of Health Ministry of Health. 2013. Guidelines for Implementation of PHC Able PONED. Jakarta Ministry of Health. 2011. Guidelines for Integrated Antenatal. D irektorat General of Health Maternal and Child Development Ministry of Health of the Republic of Indonesia. Jakarta

MOH. 2013. The Indonesia Health Profile 2013.

Retrieved from: ttp://www.depkes.go.id /resources/ download/pusdatin/profil-kesehatan-indonesia/ profil-kesehatan-indonesia-2013.pdf > (Citation October 15, 2014) Nursalam, Pariani. 20 1 1. Approach Practical Nursing Research Methodology. Jakarta: Infomedia

Abstract Empowerment the Pregnant Woman with Prenatal Class by Improve the practice of P4K to Achieve SDG’s 2030 Target and Solving the Problem on Maternal and Neonatal Mortality.

This study applied analytical observational study with cross sectional approach. The number of samples taken was as many as 30 mothers, using simple random sampling. Analysis of data was carried out using cordinal wilcoxon sign rank test. Data were obtained from interview and questionnaire. The independent variable in this study was a class of pregnant woman, while the dependent variable in this study is P4K Practice.

P4K Material consist of: Due-date of labor, Informal discussion, Labor attendant, Birth Place, Birth Companion , Question and answer, Transportation, Potential Blood Donors, The need for labor, Labor savings, Post-labor contraception, Experience sharing with Participant, Media Maternal and Child Health Book, Prenatal Class Flip Chart.

The result showed there was an influence of prenatal class to the P4K practice ( p=0,000). Statistical analysis showed differences in the practice of P4K, before, and after prenatal class was given. Lack of childbirth planning and prevention of complications in pregnant women would have the impact on pregnant woman and fetus. Through the Program of Birth Planning and Prevention of Complications (P4K) with a sticker that is sticked to the houses of pregnant woman, then every pregnant woman will be registered, recorded and monitored appropriately. So that the process of childbirth to perpetual phase including the referral can be run safely. Prenatal classes is also facilitated by blood tests for pregnant woman and families. Blood type is very important to know the compatibility between blood donors and recipients of blood. This can prevent the risk of complication during pregnancy, childbirth, or postpartum, helping pregnant woman in an emergency and taking important decisions. Prenatal class can influence to practice of P4K. Planning for childbirth and prevention of complications become one determinant of success in the management of obstetric maternal and neonatal emergency that can reduce maternal and infant mortality rate.

ABSTRACT Preeclampsia is a disorder in pregnant women that is usually characterized by the presence of protein in the urine, high blood pressure, and swelling of the hands and feet. The disease has a percentage incidence of approximately 2% -8% of pregnancies in the world with 46,900 deaths by 2015 (3). Preeclampsia can be prevented with proper diet and also with additional supplements. Provision of supplements in the form of calcium and also aspirin in pregnant women is considered effective in reducing the risk of pregnant women to suffer from preeclampsia(1)(2). Based on WHO recommendations, pregnant women are recommend to take calcium supplements as much as 1 to 2 grams daily during pregnancy starting from 20 weeks' gestation.

References 1. Duley L, Henderson-Smart D, Meher S, King J. Antiplatelet agents for preventing preeclampsia and its complications. Cochrane Database of Systematic Reviews. 2007;.

2. Henderson J, Whitlock E, O’Connor E, Senger C, Thompson J, Rowland M. Low-Dose Aspirin for Prevention of Morbidity and Mortality From Preeclampsia: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Annals of Internal Medicine. 2014;160(10):695.

3. Wang H, Naghavi M, Allen C, Barber R, Bhutta Z, Carter A et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. 2016;388(10053):1459-1544.

The Cause of Maternal Mortality in Developing Countries and How to Stop Them Yogi Prema, Tijani Zakirah, Jaya Kusuma, Rizky Dimasyah

AIM The objective of this systematic review is to analyses the cause of maternal mortality in those developing country and how to improve maternal health and prevent increasing maternal mortality rate. Through this systematic review we hope we can find an effective way to deal with maternal health gap between developing and developed country.

BACKGROUND The high number of maternal deaths in some areas of the world reflects inequities in access to health services, and highlights the gap between rich and poor. Almost all maternal deaths occur in developing countries. Based on this fact, we decided to make a systematical review on maternal heatlh situation in developing countries.

METHODS This review was conducted according to the guidelines of a systematic review Search Engines : PubMed, Google, Google Scholar Keywords : Maternal, Mortality, Developing Countries The review was done online to obtain articles focusing on the effects of exercise training on preeclampsia prevention

RESULTS & DISCUSSION So far, we’ve found three study about maternal mortality rate in developing country to discussed. These study held at some area in several developing country such as Africa, Zimbabwe, and Eithiopia. in 2008, 57% of global maternal deaths occurred in Sub-Saharan Africa and 39% in Asia (30% in Southern Asia) [1].

These high percentage of maternal mortality rate caused by many factors. In these studies we found maternal death can be caused by complication happened to the mothers or even lack of timeliness in handling the delivery. The same factors from these studies and to become the main factors in high maternal mortality rate in most of developing countries is the lack in professional medical staff and medical facilities to maintain maternal health in those countries, also the lack in proper education for every expectant mother there is. The lack of proper medical care can be caused by low economical state of those countries.

RESEARCH POST ER PRESENTAT ION DESIGN © 2015

www.PosterPresentations.com

Source : Chinkhumba et al. BMC Public Health 2014, 14:1014 http://www.biomedcentral.com/1471-2458/14/1014

To decrease maternal mortality rate in most of developing country, proper education is needed to mold every medical staff in those countries to be professional and competent healthcare workers. Proper antenatal care also needed to maintain expectant mothers’ and their foetus health and keep it in track, when certain medical treatment required then it can be done immidiately.

CONCLUSION High maternal mortality rate in developing countries are mostly caused by low economical state occurring in those countries which lead to lack of proper medical care to maintain maternal health. To prevent this, more professional healthcare is needed in those countries.

ACKNOWLEDGMENT We would like to thank the Faculty of Medicine Universitas Airlangga for supporting and AMSA UNAIR for giving us a chance to experience how to make a scientific poster.

REFERENCE 1. Sarah Z, Holly N, Doris C, Nobuko M, Lale S, Emi S, John W. Understanding Global Trends in Maternal Mortality. Int Perspect Sex Reprod Health. 2013; 39(1): . doi:10.1363/3903213.

2. Jobiba C, Manuela DA, Adamson SM, Bjarne R. Maternal and perinatal mortality by place of delivery in sub-Saharan Africa: a meta-analysis of population-based cohort studies.

BMC Public Health. 2014; 14: 1014. Available at : http://www.biomedcentral.com/14712458/14/1014.

3. Faith M, Patron TM, Tsitsi J, Notion TG, Donewell B, More M, Mufuta T. Evaluation of the maternal mortality surveillance system in Mutare district, Zimbabwe, 2014-2015: a cross sectional study. PanAfrican Medical Journal. 2017; 27:204. doi:10.11604/pamj.2017.27.204.7210.

4. Yaliso Y, Bernt L. High maternal mortality in rural south-west Ethiopia: estimate by using the sisterhood method. BMC Pregnancy and Childbirth. 2012; 12:136. Available at : http://www.biomedcentral.com/1471-2393/12/136.

Abstrak Maternal health is one of the most important thing in the medical world. The health of a baby depends on the health of the mother. A continuous care and consideration on maternal health are very essential for the health of the mother and the baby. In developing countries, they make sure that every deliveries are done in good healthcare facilities. The better the health care facilities are, the better the health of both mothers and babies are, too. But there is some problems which could stand in the way of improving maternal health. The political issues, the insufficient human resources, and weak healthcare facilities are some of them. Maternal mortality was chosen as an indicator because it is easy to measure and it can be analyzed well.

So with this, we hope we could achieve a better maternal health by reducing the rate of maternal mortality.

The Effect of Nigela sativa Ethanol Extract in Improving eNOS expression of HUVECs Model in Severe Preeclampsia Pregnancies: An in vitro Studies Putu Ijiya Danta Awatara1, Ibnu Diptya2, Alexander Fernando3, Adisty Aulia Kamarani4 University of Brawijaya

Background: According to WHO, preeclampsia complicates 2-10% of all pregnancies and is one of the leading causes of maternal death in indonesia (hemorrhage, hypertension, and infection). Maternal Mortality Rate (MMR) due to hypertension reaches the number of 97 per 100.000 births in indonesia.

Inhibiton of eNOS expression in preeclampsia caused hypertension in pregnancy. Flavonoid (Thymoquinone, dithymoquinone, and thymol) extracted from black cumin (Nigela sativa) is a major biologically active component as an anti-inflammatory and antioxidant to reduce free radicals which are useful as antihypertensive in preeclampsia.

Aim: To prove Nigela sativa extract can increase eNos expression in HUVECs model exposed to preeclampsia as an alternative treatment of preeclampsia in pregnancy.

Material and Method: The research design that is used is pure experimental research (true experimental) with post-test only control group design. The study focused on the eNOS expression with the treatment of ethanol extract of the black curmin (Nigela sativa) in vitro. Peripheral venous blood plasma from patient with severe preeclampsia is drawn and transferred to HUVECs model. And then, eNOS expression is measured using immunohistochemistry method.

Result: The result from the analysis of in vitro (using immunohistochemistry method) shows the effectiveness of black cumin (Nigela sativa) in increasing the expression of eNOS in preecalampsia HUVECs model. Stastitical analysis one-way ANOVA test showed a significant value of the data (p<0.05) and Pearson colleration test showed strong correlation (Pearson correlation: 0,763) with positive direction (increasing number of eNOS expression with every increasing dose of black cumin extract).

Conclusion: Black cumin extract (Nigela sativa) can increase eNOS expression in HUVECs model exposed to preeclampsia severe pregnancy plasma.

Abstract : Maternal mortality and stillbirth are two most devastating outcome of the pregnancy, therefore both are significantly correlated. In this study, we try to determine factors affecting the causes of maternal mortality and stillbirth and also we try to make a comparison between developing and developed country. The study is conducted by collecting data from journals and reffer to the World Health Organization data, using three kinds of obstetric measurements; antenatal visits, presence and of skilled attendant, and also cesarean section. In worldwide, maternal mortality was significantly associated with stillbirth. both were similarly related to all three measures of obstetric care. The increase rates of cesarean section from 0 to about 10% was associated to significantly decreasing for both maternal mortality and stillbirths.

Necessity of Increasing Awareness about Pre-eclampsia in Indonesia

ABSTRACT Pre-eclampsia is a life threatening multi-system disorder of pregnancy. It is generally defined as new-onset hypertension and proteinuria, occurring after 20 weeks of gestation. Numerous research had resulted in vast knowledge about preeclampsia, including its possible disorders and types of treatment. Preeclampsia can result in deaths, as globally it accounts for 10-15% of death on pregnant women. These deaths are the result of eclampsia, and complications of preeclampsia. Complications occurred more frequently in developed countries. We aim to know the importance of preeclampsia, specifically its awareness increasing’s necessity in Indonesia. The study was done by collecting various literature and journals about preeclampsia.

We used several keywords, such as pre-eclampsia, awareness, education, and Indonesia. Our study resulted that in Semarang, Indonesia, preeclampsia was one of the major causes of maternal death. It was also affected by several factors, such as passive smokers, overweight, hormonal contraception, and protein adequancy level below 100%. Data of preeclampsia in two hospitals in Jakarta also shows that education level has direct correlation to pre-eclampsia.

From these data, we concluded that preeclampsia can be prevented by education, as major factors of preeclampsia can be avoided by sufficient education. One data directly shows that women with lower education level has greater risk of preeclampsia. Preeclampsia awareness become highly necessary and increasing awareness of preeclampsia should be carried out immediately to prevent more deaths from preeclampsia.

Keywords: Preeclampsia, awareness, necessity

Maternal Factors Associated with Preeclampsia among Asian: Systematic Review of Large Cohort Studies Kristian Kurniawan*, Fabiola Cathleen, Christine Lieana, Adriana V Miranda Universitas Indonesia *kristian.k9027@gmail.com

Background: Maternal mortality is still a major problem in developing countries. World Health Organization estimates that the countries’ Maternal Mortality Rate (MMR) reaches 239 per 100.000 live births in 2015. It is very high compared to MMR in developed countries, which is as low as 12 per 100.000 live births. 25% of the problem is accounted to preeclampsia.

Objective: This paper aims to identify factors associated with preeclampsia amongst Asian in order to increase awareness and preeclampsia screening quality.

Material and method: 6133 records were found through Pubmed database searching. We then eliminate publications that did not meet our inclusion criteria (n = 6037). Cohort studies were chosen as they are able to represent pregnancy, a nine-month process. There are 96 full text articles retrieved and assessed for eligibility: 15 of which are included in the study after assessments using exclusion criteria.

Results: 375.622 participants from 15 studies were included. STROBE Statement was used to assess the included cohort studies for systematic review to improve the quality of reporting. With the score of 20.4 out of 22, Li X, et al. 2015 becomes the best study. The studies show that risk factors of preeclampsia Maternal BMI and history of gestational hypertension and preeclampsia is risk factor of preeclampsia most discussed and problematic in Asia. Risk factors with highest odd ratio are pregestational obese (OR: 7.85); chronic hypertension (OR: 7.174); and previous history of gestational hypertension or preeclampsia (OR: 8.85), respectively. Weight gain below IOM in overweight pregestational weight (OR: 0.76), Isolated anti TPO antibody, normal BMI, BPD >90 (OR: 0.86), maternal weight gain <10kg and maternal weight gain ≥ 16 kg (OR:0.6) are shown as protective factors of the condition.

Conclusion: This systematic review proves the role of maternal BMI (overweight and obese), inappropriate maternal weight gain and history of pre-gestational hypertension and preeclampsia as risk factors commonly found amongst Asian. Other risks of the problem include maternal age, mother’s education, mother activity, diabetes mellitus and hypothyroidism. The knowledge is aimed to improve the quality of preeclampsia screening and awareness.

BuahHati : Mobile Application-based Notification & Integrated Communication System for Maternal Health Services to Reduce Maternal Mortality & Morbidity Rate in Indonesia

M.Vico Rizkita, Savannah Quila Thirza, Theresa Puspanadi, Andra Danika ASIAN MEDICAL STUDENTS’ ASSOCIATION BRAWIJAYA UNIVERSITY

Every 90 seconds a woman dies of complications related to pregnancy and childbirth, resulting a total of 340.000 maternal deaths a year. Until now, maternal health remains a significant problem in developing countries. MDG 8 states the need to create advantages of new technologies available, especially those related to information and communication. BuahHati is a rebrand of existing technology called mHealth, it is a mobile application based system which has the potential to facilitate and provide emergency obstetric service through integrated notification and communication system especially in rural areas in Indonesia with comprehensive purpose to improve access for quality of obstetric care. This system focuses on creating a proactive community in prepping for safe delivery, optimalize referral system of obstetric emergency, and reducing phases of delays in receiving and seeking medical care for emergency cases. A systematic review on the use of mHealth reported multiple implementations of these innovation, including field data collection, receiving alerts and reminders, facilitating health promotion and education, and communication between providers. This systematic review found that mobile phone technology in the context of maternal health has been evaluated over a range of service delivery applications, such as data collection, provider-to-provider communication, appointment reminders, health education, and clinical follow-up. Studies showed qualitative findings for this technology, including health education and appointment reminder messaging significantly increasing antenatal and postnatal care and associated with the potential of reducing maternal mortality rate. Overall, this review highlights the need for further higher-quality evidence to reinforce specific mHealth designs and applications to the health care delivery setting for maternal health.

THE CORRELATION BETWEEN PARITY AND CERVICAL CANCER AMONG PATIENT IN DR. SAIFUL ANWAR HOSPITAL MALANG Meilia Zainudin1, Putu Ijiya Danta Awatara2, Reselina Utami3, Yogesvara4 University of Brawijaya Background: Cancer may occur in female reproductive organs, such as breasts, cervix, ovaries, and vagina. In Indonesia, there are over 15.000 cases of cervical cancer, with around 8.000 deaths occur annually. In 2006, Anatomy Pathology Association of Indonesia reported that mortality rates due to cervical cancer in Indonesia is very high because most of the patients came with cervical cancer at an advanced stage or terminal stage. Human papilloma virus (HPV) is the main cause of cervical cancer.

Aims : to investigate the correlation between parity and occurrence of cervical cancer.

Methods: This is an observational analytic study with case control design using secondary data of cervical cancer cases and controls that meet the inclusion criteria. It was conducted in Dr. Saiful Anwar Hospital, Malang in 2012-2014. Data will be processed using SPSS application with spearman and chi square correlation statistic analysis with 95% confidence level and α 0,05.

Results: Based on Chi-Square test showed a significant relationship between the number of parity with cervical cancer (p =0.015 and χ2 = 5,939, and the value of χ2 tables with degrees of freedom = 1, and the error rate of 5% is 3.841, χ2 = 5,939 is bigger than value χ2 table = 3,841 or p value = 0,015 <5% (α = 5%). Spearman study showed a weak correlation between parity and cervical cancer (R=0,246).

Conclusion: Parity is one of the risk factor of cervical cancer but not the main cause. There is a significant relationship between parity as one of the risk factors of cervical cancer. The incidence of cervical cancer are higher in samples with the number of partial ≥3 as evidenced in the study that women with parity ≥3 had a risk of cervical cancer ± 3X compared with women with parity <3 with the largest proportion is women with the number of parity 3.

Keyword: Parity, Cervical Cancer, Risk Factor

Author : 1

Meilia Zainudin 089693239707 meiliazainudin@gmail.com

2

Putu Ijiya Danta Awatara 081232270119 ijiyadanta19@gmail.com

3

Nuansa Firgie Paramitha

081230080113 nuansafirgieparamitha@gmail.com 4

Aisha Putri S.

085811498317

imelicha@gmail.com

Regional Chairperson of AMSA Indonesia : Elvira Lesmana +6285811240637 rcindonesia@amsa-international.org

ABSTRACT

Nowdays, the discrepancy maternal health issue in developed n developing country still high. Main pr oblem in obstetric included preterm delivery low caused by poor sanitary, birth weight and neonatal m ortality due to bacterial vaginosis. We used meta-analysis method to compose this journal. Five journa ls are used as source of information. The prevalence of BV appeared to increase 36% in the third seme ster. Mothers who had taken antibiotics recently was found higher (70%) than the mothers who did no t take antibiotics (34%). With P = 0.028, it shows that there is a positive association between recent an tibiotic intake and BV infection. From the meta-analysis that we have done shows that there is a positi ve association between recent antibiotic intake and BV infection and the use of probiotics can reduce t he infectious in urinary tract.

Neonatal Health Interventions to Meet MDG Targets Muhammad F. Aziz, Jonathan C. Sutadji, Moch. N. Alzamzami, Nadhifah AMSA Chapter Indonesia

Introduction The global burden of neonatal and child mortality is alarmingly high in low and middle income countries (LMICs). There has been a sharp decline in mortality rates in children under five years of age between 1990 and 2013 (from 90 mortalities per 1000 down to 46 mortalities per 1000 live births between 1990 and 2013). Despite all the progress made in the last decade, it is very unlikely that the MDG targets (30 mortalities per 1000) live births will be met in many LMICs, where 99% of global deaths occur [1]. In developing countries, a variety of interventions could substantially reduce deaths and improve maternal and perinatal health. However, a major obstacle in meeting the proposed reduction is that most neonatal and child health programs do not reach to those who need it the most.

Therefore, effective interventions and care-based strategies need to be widely deployed to all and be delivered across the continuum of reproductive, maternal, neonatal and child health (RMNCH) care.

Materials & Methods

Discussions There have been many great successes in reducing neonatal mortality as part of the MDGs; however, the current rates are still too high since each year 2.9 million newborns do not live to their first month of life (Berkley et al., 2014). In order to accelerate the progress towards reaching the targets set for 2015, this overview aimed to identify key interventions for neonatal and later survival.

Review of all the recent Cochrane and other reviews on pre-pregnancy, pregnancy, neonatal and child health interventions which have reported perinatal or neonatal and child mortality identified six highly effective and 11 promising interventions which are likely to improve health and survival among babies.

Several limitations do however need to be recognized. First, it is important to consider that many of the interventions assessed in this review demonstrated important reductions in morbidity but may have been underpowered to show differences in neonatal and later survival. Second, it is also important to be aware that some clearly effective interventions, such TT immunization during pregnancy for reducing tetanus related mortality in neonates do not rate highly on GRADE, due to the study designs required to address this issue.

Third, it is not possible to account for all the biases involved in the individual primary studies during the conduct of an overview of systematic

➢

In this overview of reviews, we have included all published Cochrane and the most recent (most latest on the given subject) other systematic reviews of randomized, non-randomized controlled trials of interventions and observational studies.

➢

reviews, where only systematic reviews and not individual primary studies are included. In addition, the high level synthesis of an overview may not always capture important contextual factors, such as educational attainment, socio-economic status, and access to care.

We addressed two different quality assessments in this overview: the quality of evidence in the included reviews using the Grading

Conclusion

of Recommendations Assessment, Development and Evaluation (GRADE) approach [2, 3]. ➢

We summarized the main results of the included reviews into following categories: •

What works

•

What might work

•

Insufficient evidence to make judgment

Effective Interventions

The implementation of these interventions will help in achieving the targets set for MDGs 4 and 5. Adoption of effective

Promising interventions

interventions promises a much needed improvement in neonatal and child outcomes around the world, especially if selected depending

ineffective interventions

on the clinical indications and keeping in mind the need for cost-effectiveness in view of the limited resources in LMICs.

Results

References 1. You, D., New, J.R., Wardlaw, T., 2013. Levels and trends in child mortality: estimates developed by the UN Inter-agency Group for child Mortality Estimation (IGME) - report 2013. World Bank, Washington DC. 2. Guyatt, G.H., Oxman, A.D., Vist, G.E., et al., 2008. Rating quality of evidence and strength of recommendations: GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 336 (7650), 924.

3. Oxman, A.D., Group, G.W., 2004. Grading quality of evidence and strength of recommendations. BMJ 328 (19), 1490–1494.

4. Lassi, Z.S., Middleton, P.F., Crowther, C., Bhutta, Z.A., 2015. Interventions to improve neonatal health and later survival: An overview of systematic reviews. EBioMedicine Journal. 2(8): 985-1000.

5. Mwansa-Kambafwile, J., Cousens, S., Hansen, T., Lawn, J.E., 2010. Antenatal steroids in preterm labour for the prevention of neonatal deaths due to complications of preterm birth. Int. J. Epidemiol. 39 (Suppl. 1), i122–i133.

6. Debes, A.K., Kohli, A., Walker, N., Edmond, K., Mullany, L.C., 2013. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health 13 (3), 1–14.

7. Imdad, A., Mullany, L.C., Baqui, A.H., et al., 2013a. The effect of umbilical cord cleansing with chlorhexidine on omphalitis and neonatal mortality in community settings in developing countries: a meta-analysis. BMC Public Health 13 (Suppl. 3), S15.

8. Conde-Agudelo, A., Díaz-Rossello, J.L., 2014. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst. Rev. (4) (Art. No.: CD002771).

9. Lengeler, C., 2004. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database Syst. Rev. 2 (2) (Art. No.: CD000363).

10. Imdad, A., Herzer, K., Mayo-Wilson, E., Yakoob, M.Y., Bhutta, Z.A., 2010. Vitamin A supplementation for preventing morbidity and mortality in children from 6 months to 5 years of age. Cochrane Database Syst. Rev. 12 (12) (Art. No.: CD008524).

11. Dowswell, T., Carroli, G., Duley, L., et al., 2010. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst. Rev. 10 (10) (Art. No.: CD000934).

The overview included 61 reproductive, maternal, newborn and child health interventions to assess their impact on neonatal and child survival. A total of 148 systematic reviews were identified for these 61 RMNCH interventions [4]. Using the GRADE approach, we identified 6 interventions to be clearly effective[5,6,7,8,9,10] and 11 promising interventions for reducing neonatal, infant, child or perinatal mortality[11,12,13,14,15,16,17,18,19,20,21} and a further four interventions were rated as promising for reducing stillbirths.

Eighteen interventions showed insufficient evidence of benefit in one or more of the mortality categories [4].

12. Blencowe, H., Lawn, J., Vandelaer, J., Roper, M., Cousens, S., 2010a. Tetanus toxoid immunization to reduce mortality from neonatal tetanus. Int. J. Epidemiol. 39 (Suppl. 1), i102–i109.

13. Radeva-Petrova, D., Kayentao, K., ter Kuile, F.O., Sinclair, D., Garner, P., 2014. Drugs for preventing malaria in pregnant women in endemic areas: any drug regimen versus placebo or no treatment. Cochrane Database Syst. Rev. (10) (Art. No.:CD000169) 14. Gamble, C., Ekwaru, J.P., ter Kuile, F.O., 2006. Insecticide-treated nets for preventing malaria in pregnancy. Cochrane Database Syst. Rev. 2 (2) (Art. No.: CD003755).

15. Gulmezoglu, A.M., Crowther, C.A., Middleton, P., Heatley, E., 2012. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst. Rev. 6 (6) (Art.No.:CD004945).

16. Zaidi, A.K.M., Ganatra, H.A., Syed, S., et al., 2011. Effect of case management on neonatal mortality due to sepsis and pneumonia. BMC Public Health 11 (Suppl. 3), S13.

17. Soll, R., Ozek, E., 2009. Multiple versus single doses of exogenous surfactant for the prevention or treatment of neonatal respiratory distress syndrome. Cochrane Database Syst. Rev. 1 (1) (Art. No.: CD000141).

18. Ho, J., Subramaniam, P., Henderson-Smart, D., Ho JJ, Davis P., Subramaniam, P., HendersonSmart, D.J., Davis, P.G., 2002. Continuous distending pressure for respiratory distress in preterm infants. Cochrane Database Syst. Rev. 2 (2) (Art. No.: CD002271).

19. Meremikwu, M.M., Donegan, S., Sinclair, D., Esu, E., Oringanje, C., 2012. Intermittent preventive treatment for malaria in children living in areas with seasonal transmission. Cochrane Database Syst. Rev. 2 (2) (Art. No.: CD003756).

20. Theodoratou, E., Al-Jilaihawi, S., Woodward, F., et al., 2010. The effect of case management on childhood pneumonia mortality in developing countries. Int. J. Epidemiol. 39 (Suppl. 1), i155–i171.

21. Lassi, Z.S., Haider, B.A., Bhutta, Z.A., 2010. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst. Rev. 11 (11) (Art. No.: CD007754).

Six Effective interventions for improving survival among babies and children: Neonatal Mortality Reduction Rate.

m co . on ss i se r e st o p . w w w

Neonatal Health Interventions to Meet MDG Targets

Muhammad F. Aziz, Jonathan C. Sutadji, Moch. N. Alzamzami, Nadhifah Faculty of Medicine Universitas Airlangga AMSA Chapter Indonesia

ABSTRACT the current rates of neonatal mortality are still too high since each year 2.9 million newborns do not live to their first month of life. A variety of interventions could substantially reduce deaths and improve maternal and perinatal health. Review of all the recent Cochrane and other reviews on prepregnancy, pregnancy, neonatal and child health interventions which have reported perinatal or neonatal and child mortality identified six highly effective and 11 promising interventions which are likely to improve health and survival among babies. However, a major obstacle in meeting the proposed reduction is that most neonatal and child health programs do not reach to those who need it the most. Therefore, effective interventions and care-based strategies need to be widely deployed to all and be delivered across the continuum of reproductive, maternal, neonatal and child health (RMNCH) care. The implementation of these interventions will help in achieving the targets set for MDGs 4 and 5.

Aspects of Infections that Affects Neonatal Mortality Nabila Ananda Kloping*, Alverina Cynthia Sukmajaya*, Wynne Widiarti* *First Year Medical Student, Universitas Airlangga.

ABSTRACT:

Aim: The aim of this review is to assess the aspects of infections that affects the mortality in neonatal.

Background: The three major causes of neonatal deaths worldwide are infections (36%), prematurity (28%), and asphyxia (23%). The cause of infections has the highest prevalence compared to others.

Also, there are many kinds of infections with different prevention and cure for each of them, which need to be explored more thoroughly. Globally, neonatal mortality has steadily decreased but the progress has been slowing especially in Asian developing countries with difficulties such as lowincome community, and not enough access to healthcare for infection management. Also, The Millennium Development Goal to reduce child mortality by two thirds is still not yet achieved.

Material and Methods: A systematic review through journals and valid websites.

Results: Neonatal mortality usually occurs in developing countries because of the difficulty to have access to healthcare facilities as well as finding clean water, not enough food, lack of hygiene and sanitation, and low levels of education.

Conclusion: This review expands the aspects of infections in neonatal mortality, proving that there are still a lot that need to be fixed, especially for developing countries that is facing many difficulties to reduce the number of their neonatal deaths.

Influence of IFA supplement intake on decreasing iron deficiency anemia through pregnancy Novi Kurnia, Novelina Gracea, Raflianda Adil, Rininta Dewi University of Brawijaya

ABSTRACT Anemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs. Iron deficiency, a condition where there is not enough iron in the hemoglobin to carry oxygen throughout the body, is one of the most common causes of anemia in pregnancy. Severe or untreated iron deficiency anemia during pregnancy can increase the risk of having low birth weight baby and can also lead to poor cognitive function, behavioral problems, and impaired psychomotor development.

According to the Nutrition Impac Model Study 2011 estimates, the worldwide prevalence of anemia in pregnant women was 38%, translating into 32 million pregnant women globally. Meanwhile in Indonesia, according to Center for Health Research University of Indonesia conducted in 2016, a high prevalence rate of anemia cases among pregnant women with the highest prevalence rate was found in East Nusa Tenggara, where it reached 44%. Due to the persistently high burden of disease, the World Health Organization has long recommended the prenatal use of IFA (iron-folic acid) in both low and high income countries. When the IFA supplementation programs were implemented across Indonesia, the success was found to vary between the 3 provinces this study focused on.

Anemia still becomes a problem in both developing and developed countries. It is one of the preventable disease that may become a burden to the nation. In order to decrease the prevalence rate of anemia especially in pregnancy, we suggest that IFA supplementation programs must be carried out thoroughly to many areas in Indonesia especially the remote ones with collaborative works between ministry of health and local health services.

THE ALTERNATIVE ANTIBIOTIC THERAPY FOR PRETERM PREMATURE RUPTURE OF MEMBRANE USING BANYAN HANGING ROOTS (FICUS BENJAMINA): INSILICO AND INVITRO STUDIES Putu Sri Maharani Utami1, Desak Gede Yuliana Eka Pratiwi2, Putu Ayu Tania Krisna Putri3, Kadek Putri Paramita Abyuda4 University of Brawijaya Aim: To determine the antimicrobial effects of Banyan Hanging Root Extract (Ficus benjamina) as an alternative treatment for preterm premature rupture membrane caused by Staphylococcus aureus bacteria by invitro and insilico.

Background: Infection is giving 32.53% of maternal death according data that was collected in 2015.

Studies showed that infection of Staphylococcus aureus causes the preterm premature rupture membrane associated with premature birth and neonatal disease. In fact, progress in infection control is threatened by the rapid development and spread of antibiotic drug resistance. Flavonoid and Tannin extracted from Banyan Hanging Root (Ficus benjamina) is a major biologically active component to inhibit nucleic acid synthesis and destruct bacterial cell walls. Flavonoid and tannin has an important role in controlling Staphylococcus aureus growth and incident of infection in maternal and neonatal health.

Material and Method: The research design that is used is pure experimental research (true experimental) with post-test only control group design. The study focused on the state of Staphylococcus aureus bacteria with the treatment of ethanol extract of the banyan hanging root (Ficus benjamina) in vitro by the wells diffusion method. Insilico (computation) research was needed by using data that exist in online database. Operation system that was used is Microsoft Windows 10 with Google Chrome browser verse 53.0.2785.116 m, Pyrx 8.0, Pymol, Vega ZZ, and Discovery Studio.

Results & Discussion: The result from the analysis of invitro (using well diffusion method) shows the effectiveness of Banyan Hanging Roots Extract (Ficus benjamina) in inhibiting the growth of Staphylococcus aureus is generally in line with the increase of extract concentration. Administration of Banyan Hanging Roots Extract (Ficus benjamina) against Methicillin-Resistant Staphylococcus aureus showed that the inhibition zone at the lowest concentration 5% is 6.74 mm and at the highest concentration 100% is 19.40 mm. The result from the analysis of insilico (supported by pyrex software) shows tannin strongly binds to LasR in their amino acid active site such as Tyr sequence 56, trp 60 (a) Asp 73, Try 75, Ser 129. The binding affinity among tannin and LasR amino acid is -7.8 kcal / mol -3.7 kcal/mol as the highest score and the lowest one is -7.1 kcal / mol.

Conclusion: Banyan Hanging Roots Extract (Ficus benjamina) has an antimicrobial effect and can be an alternative treatment for preterm premature rupture membrane caused by Staphylococcus aureus using invitro and insilico method.

Keywords: Staphyloccus aureus, Preterm premature rupture of membrane, Antibiotic, Flavonoid, Tanin, Ficus benjamina, Extract, Invitro, Insilico

Author : 1

Putu Sri Maharani Utami 082144003396 dindamaharani369@gmail.com

2

Desak Gede Yuliana Eka Pratiwi 082145907203 yulianapratiwidesak@gmail.com

3

Putu Ayu Tania Krisna Putri 087787025370 Taniakrisna1@gmail.com

4

Kadek Putri Paramita Abyuda 085333005809 putri.abyuda@gmail.com

ABSTRACT This study has a purpose to learn about maternal and neonatal health that can effected by nutrition factor. This study use case control as the method, by comparing the various variations in maternal and neonatal mortality rates in various countries in both developing and developed countries. The material that has been used is from number of maternal and neonatal mortality in several country that is cause from many factor, one of them is malnutrition. Why we used that as our study's base? Of course because from that cases we can learn the condition of maternal and neonatal health especiallly in Indonesia. The result of this study is that nutrition has an important function that can effect to maternal and neonatal health especially to the mortality and deformity.

Yoga as an Alternative for Reducing Prenatal Depression Satrio Wahyu Nugroho Naufal Dany Kurniawan Fajar Daffa Aulia Ferrel Bramasta Introduction

Discussion

Pregnancy is one of the most important time in women's life. At this point, some women will face some depression during pregnancy. This kind of depression is called prenatal depression. Prenatal depression has been noted to affect as many as 49% of pregnant women.1 Prenatal depression can negatively affect the physical and mental health of both mother and fetus.2 If pregnant women's distress, similar to their nutrition, is influencing children's long–term development, i.e., if fetal exposure to the physiological alterations associated with women's psychological distress affects child outcomes, evidence of this maternal influence should be detectable during the prenatal period.3 We heard some pregnant women society suggesting yoga as a daily exercise to improve mental and physical health of pregnant women and fetus. While conventional medicine is available, we believe that yoga can help to reduce this prenatal depression. It's a cheaper and healthier option than using conventional medicine for depression since conventional medicine can affect the health both of the mother and the fetus. From that, we are trying the truth about the benefits of yoga for pregnant women.

With the results that we have found, we confirmed that yoga is beneficial for pregnant women. Not only reducing prenatal depression, it also reduces the anxiety and sleep disturbances of pregnant women. This means with yoga, pregnant women can be more healthy, less depressed, and maybe even improve the happiness of the pregnant mother. Moreover, this also means that yoga can also prevent the negative effects of prenatal depression for the fetus. We also confirmed that prenatal yoga is not only beneficial for the pregnant women, but also for her fetus after the labor day.

Material and Methods We gathered the information from numerous sources that discuss about prenatal depression and the effects of yoga for pregnant women. We also search for the effects of prenatal depression to pregnant women and fetus in pregnancy time. From those information, we compare the information between the sources and then we analyze the information that we have compared. Numerous research experiment involving pregnant women as the subject of the research. Those research including different types of yoga such as integrated yoga and physical-exercisebased yoga.3 From all of the information that we have gathered, we compile all of the information and choose the information that is mostly showed in all of those sources that we use.

Results We found that prenatal depression cause some effects that are dangerous for the health of pregnant women and her fetus such as 1. Prenatal stress and feelings of general anxiety have been linked to lower birth weight.4 2. Difficult temperament and behavioral problems.5 3. Pregnancy-specific anxiety between 13 and 17 weeks of gestation to be a unique predictor of negative child temperament at 2 years.6 From numerous sources that we have analyzed, we also found that yoga can reduce prenatal depression symptoms in pregnant women. Not only prenatal depression, pregnant women who do yoga in their pregnancy time also have lower anxiety level and lower sleep disturbances level.1 found that yoga can reduce prenatal depression symptoms in pregnant women. Not only prenatal depression, pregnant women who do yoga in their pregnancy time also have lower anxiety level and lower sleep disturbances level.1

Conclusion We conclude that yoga for pregnant women can reduce prenatal depression and improve the health of the mother and the fetus before labor day. Yoga is also one of the cheaper alternative to conventional medicine in reducing the prenatal depression on pregnant women.

Bibliography/Acknowledgement 1. Walker M, Kublin JG, Zunt JR. Tai chi/yoga reduces prenatal depression, anxiety and sleep disturbances. NIH Public Access. 2009;42(1):115–25.

2. Hong Gong, Chenxu Ni, Xiaoliang Shen, Tengyun Wu, Chunlei Jiang. Yoga for prenatal depression: a systematic review and meta-analysis. BMC Psychiatry.

2015;15(1):14.

3. Kinsella MT, Monk C. Impact of Maternal Stress, Depression & Anxiety on Fetal Neurobehavioral Development. Clin Obstet Gynecol [Internet].

2009;52(3):425–40.

4. Lobel, M., Dunkel-Schetter, C., Scrimshaw, S.C., 1992. Prenatal maternal stress and prematurity: a prospective study of socioeconomically disadvantaged women. Health Psychol. 11, 32—40.

5. Huizink, A.C., de Medina, P.G.R., Mulder, E.J.H., Visser, G.H.A., Buitelaar, J.K., 2003. Stress during pregnancy is associated with developmental outcome in infancy. J. Child Psychol. Psychiatry 44, 810—818.

Yoga as an Alternative for Reducing Prenatal Depression Universitas Airlangga Authors Satrio Wahyu Nugroho Naufal Dany Kurniawan Fajar Daffa Aulia Ferrel Bramasta Aim To prove that yoga is an available alternative methods to reduce prenatal depression on pregnant women.

Background Pregnancy is one of the most important time in women’s life. At this point, women will face some stress and depression during pregnancy. Prenatal depression has been noted to affect as many as 49% of pregnant women.1 Prenatal depression can negatively affect the physical and mental health of both mother and fetus.2 While conventional medicine is available, we believe that yoga can help to reduce this prenatal depression. It’s a cheaper and healthier option than using conventional medicine for depression since conventional medicine can affect the health both of the mother and the fetus.

Material and Methods We gathered the information from numerous sources that discuss about prenatal depression and the effects of yoga for pregnant women. We also search for the effects of prenatal depression to pregnant women and fetus in pregnancy time. From those information, we compare the information between the sources and then we analyze the information that we have compared.

Results From numerous sources that we have analyzed, we found that yoga can reduce prenatal depression symptoms in pregnant women. Not only prenatal depression, pregnant women who do yoga in their pregnancy time also have lower anxiety level and lower sleep disturbances level.1 Discussion

With the results that we have found, we can see that yoga is beneficial for pregnant women.

Not only reducing prenatal depression, it also reduces the anxiety and sleep disturbances of pregnant women. This means with yoga, pregnant women can be more healthy, less depressed, and maybe even improve the happiness of the pregnant mother.

Conclusion We conclude that yoga for pregnant women can reduce prenatal depression and improve the health of the mother and the fetus before labor day. Yoga is also one of the cheaper alternative to conventional medicine in reducing the prenatal depression on pregnant women.

“Correlation Between Low Birth Weight and Neonatal Mortality Rate” Sergio Paipinan, Jonathan Savero Simanjuntak, Brando Lourdes Yehezkiel Panjaitan AMSA Universitas Kristen Indonesia

Background : Low Birth Weight (LBW) is still a significant public health problem globally and is associated with a range of both short and long term consequences. Approximately, 15% to 20% of births worldwide are LBW. Every year, 1.1 million babies die from complications of preterm birth, which is also the most common direct cause. Low birth weight is also causes prenatal mortality and morbidity and also many diseases in the future.

Objective Weight.

: To find the solution to decrease the Neonatal Mortality Rate caused by Low Birth

Method : The method we use is systematic review pattern, where the sources we use are from NEJM, BMJ, PubMed, WHO, and Indonesian Demographic and Health Survey (IDHS) 2012, searched by Google Scholar search engine. From 30 journals, inclusion criteria refers to “Low Birth Weight” and “Neonatal and Infant Mortality Rate”, keyword with inclusion between 2001-2016 and the exclusion data are excluded from that.

Result : The result shows that there are many correlated factors between low birth weight and neonatal mortality rate, such as malnutrition, preterm birth, multiple pregnancies, congenital disorder and deformity, infections and chronic conditions. All of that will make the low weighted baby develop poor cognitive, mental, and body state and also increase risk of chronic disease later in life.

Conclusion : A smart solution is needed to solve this global scale health problem. One of the example is WHA Global Nutrition Targets 2025: Low Birth Weight Policy Brief which targets 30% reduction of low birth weight at 2025. This program is focusing on action, iterventions, and policies to help reducing low birth weight in the cost-effective way and it also automatically reduces neonatal mortality rate.

Keyword

: Low birth weight, neonatal and infant mortality rate, low birth weight stastistics

Contact Details Regional Chairperson AMSA-Indonesia Name : Elvira Lesmana Email : rcindonesia@amsa-international.org Phone : +6285811240637

The Role of Physical Activity on the Prevention of Preeclampsia in Pregnant Women: a Systematic Review Faculty of Medicine Universitas Airlangga Valerie Afiyah, Wigaviola Socha, Danise Febiola, and Yusra Nabila While two other studies showed contrasting Results

Introduction

Preeclampsia affects 2 to 8 percent of

We found 4 journals coherent with the purpose of our review.

activity has no correlation with the prevention

pregnancies and this complication is a

of preeclampsia. One study even concluded

major cause of maternal and fetal mortality

that physical activity may increase the risk of

and morbidity.1 Although the research is comprehensive,

the

etiology

preeclampsia.

of

preeclampsia is poorly understood. On that

But there were also limitations to these

matter, preeclampsia is a complication during

pregnancy

hypertension

that

and

Table 1. The effects of physical activity during pregnancy on the occurrence of gestational diabetes mellitus, preeclampsia, and other fetomaternal outcomes may be mediated through multiple independent and overlapping biological pathways. 3

incorporates

organ

preeclampsia

damaging.

hypertension

and

problems

have

other resulted

approximately 76.000 deaths of the mothers

First author, Subject

Activity details

Main findings

Sorensen4

201 preeclamptic and -Any physical activity

-Women who engaged in exercise during pregnancy (35%

2003

383 normotensive

(hours and intensity)

reduced risk of preeclampsia)

Retrospectiv pregnant women

-Walking (distance and

-Compared with inactive women, those engaged in light

e study

pace)

or moderate activities experienced a 24% reduced risk of

-The corresponding reduction for women participating in

there is a role of exercise in the prevention of

vigorous activities was 54%.

There has been

-Brisk walking was associated with a 30% to 33%

research that conclude that physical activity

reduction in preeclampsia risk.

-Stair climbing was inversely associated with the risk of

a

role

of

the

prevention

of

preeclampsia.

preeclampsia (P for trend 0.039).

Material and Methods

-Participants who reported feeling very strenuous to

Rudra 5

244 preeclampsia

Recreational physical

2005

cases and 470

activities in the year before maximal exertion during usual prepregnancy physical

Retrospectiv normotensive e study

controls

pregnancy (perceived

activity were 78% less likely to have developed

exertion, type, frequency,

preeclampsia).

and duration)

-A significant trend was noted of decreased preeclampsia risk with increased perceived exertion (P < 0.001).

the PRISMA guidelines of a systematic

performed during the year before pregnancy was

-Relative intensity of recreational physical activity

associated with a decreased risk of preeclampsia.

review. Analyzing journals using search

Using Key Words: preeclampsia or pre-

Table 2. Studies that indicate a possible role of physical activity on the prevention of preeclampsia

First author,

activity,

and

pregnancy.

The

-Physical activity in first

-The study was unable to document a

2009

Danish women, recruited

trimester (type, frequency,

protective effect of leisure time physical

Prospective

between 1996 and 2002.

duration)

activity against pre-eclampsia.

cohort

focuses on the role of physical activity on the prevention of preeclampsia, especially studies

be

more

studies

concerning

this

topic

specifically and other possible preventions for preeclampsia like Dietary Approaches to Stop Hypertension (DASH) and sodium intake that could help improve maternal and neonatal

References 1.

Kuklina EV, et al. Hypertensive Disorders and Severe Obstetric Morbidity

2.

Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-

3.

Dempsey, Jennifer C , Butler, Carole L, Williams , Michelle A. No Need

-The data even suggest that leisure time

in the United States. Obstet Gynecol 2009; 113:1299-306

physical activity exceeding 270 minutes/week in first trimester may increase risk of severe pre-eclampsia.

on preeclampsia prevention.

Inclusion Criteria

eclampsia. Lancet. 2010;376(9741):631–644.

for a Pregnant Pause: Physical Activity May Reduce the Occurrence of

• Language : English

Vollebregt7

128 Pregnant women with

2010

preeclampsia in Amsterdam time in the past week (type,

Population

Physical activity in leisure

intensity, and duration)

based

• Subject : pregnant women outcomes

lack of quality and quantity of studies that

health.

A total of 85,139 pregnant

concerning the effects of physical activity

• Minimal

Main findings

design Østerdal ML6

review was done online to obtain articles

Activity details

year, Study

eclampsia and exercise, exercise training or physical

Subject

preeclampsia in pregnant women. Due to the

with solid and reliable data. So there should

This review was not conducted according to

engines : PubMed and google scholar.

Conclusion From this review we cannot conclude that

-Climbing stairs (how many preeclampsia. flights)

has

assessment of exercise during pregnancy was based on a short time frame.

design

and 500.000 deaths of the unborn babies every year conservatively.2

studies such as no information of prepregnancy exercise, limited sample size, and

year, Study

Globally,

results, indicating that the role of physical

:

preeclampsia,

The amount of time or intensity of physical

Gestational Diabetes Mellitus and Preeclampsia. American College of

activity in leisure time was not associated

Sports Medicine . 2005

with a difference in risk of preeclampsia or gestational hypertension.

4.

Sorensen TK, Williams MA, Lee IM, Dashow EE, Thompson ML, Luthy

Prospective

DA. Recreational physical activity during pregnancy and risk of preeclampsia.

study

Hypertension. 2003; 41:1273-1280.

• Subject : males, nonpregnant women

Table 3. Studies that indicate there being no correlation even negative effect on the role of physical activity on the prevention of preeclampsia

diabetes, hypertension • No minimal outcomes

Discussion

Exclusion Criteria:

From the 4 studies that we use, two studies

• Language : Non-English

showed a protective role of physical activity on preeclampsia risk.

Physical activity ranging

ABSTRACT

The Role of Physical Activity on the Prevention of Preeclampsia in Pregnant Women: a Systematic Review Faculty of Medicine Universitas Airlangga Valerie Afiyah, Wigaviola Socha, Danise Febiola, and Yusra Nabila

Aim The review was done to examine the role of physical activity on the prevention of preeclampsia in pregnant women.

Background Preeclampsia affects 2 to 8 percent of pregnancies and this complication is a major cause of maternal and fetal mortality and morbidity. Although the research is comprehensive, the etiology of preeclampsia is poorly understood. On that matter, preeclampsia is a complication during pregnancy that incorporates hypertension and organ damaging. Globally, preeclampsia and other hypertension problems have resulted approximately 76.000 deaths of the mothers and 500.000 deaths of the unborn babies every year conservatively. There has been research that conclude that physical activity has a role of the prevention of preeclampsia.

Material and Methods This review was not conducted according to the PRISMA guidelines of a systematic review and was done online. Analyzing journals using search engines : PubMed and google scholar. Using Key Words: preeclampsia or pre-eclampsia and exercise, exercise training or physical activity, and pregnancy.

Results We found 4 journals coherent with our main research question.From the 4 studies that we use, two studies showed a protective role of physical activity on preeclampsia risk. Physical activity ranging from walking, biking, to climbing stairs, are used as one of the types of physical activity that the subjects did. Also measuring the distance, intensity, and frequency of the physical exercise whether before or during pregnancy have been found to reduce the risk of preeclampsia. While two other studies showed contrasting results, indicating that the role of physical activity has no correlation with

the prevention of preeclampsia. One study even concluded that physical activity may increase the risk of preeclampsia.

Conclusion From this review we cannot conclude that there is a role of exercise in the prevention of preeclampsia in pregnant women.

KNOWLEDGE AND CONSUMPTION OF FOLIC ACID SUPPLEMENTS BEFORE AND DURING PREGNANCY ON WOMEN WHO LIVED IN DOWNTOWN AND COASTAL AREAS IN SURABAYA, INDONESIA Ika Puji Dana Savitri, Belinda Anasthasya Tansy, Azarine Neira Avisha, Nuruddin Dzulkarnain Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia

ABSTRACT

Aim The purpose of the study was to determine knowledge and consumption of folic acid supplements before and during pregnancy in Surabaya, Indonesia.

Background Of 7.7 million child deaths in 2010 worldwide, approximately 3.1 million were neonatal deaths.

Approximately 75% of neonatal deaths occur in the early neonatal period, or the first 7 days after delivery and 50% occur in the first 24h. As of 2012, Neonatal Mortality Rate (NMR) and Infant Mortality Rate (IMR) in Indonesia have declined to 15 and 26 per 1,000 live births, respectively.

However, the decline did not meet the Millennium Development Goal (MDG) target, that was to reduce child mortality by two-third by 2015. One factor that was known to have a significant role in reducing neonatal and infant mortality as well as preventing neural tube defects was the consumption of folic acid before and during pregnancy. Therefore, this important issue was elaborated in this paper.

Material and methods This descriptive study was carried out using a cross sectional design on 100 women who had children and lived in downtown and coastal areas of Surabaya, East Java, Indonesia. The demographic, knowledge and consumption of folic acid supplements data were obtained using a questionnaire. All study participants agreed to sign the informed consent voluntarily. The research ethics approval was acquired from the Human Research Ethics Committee at Hang Tuah University (No. 8/M/KEPUHT/X/2017).

Results Majority of study participants were housevives and their mean age was 41 years old. The chi square tests showed that women who lived in downtown area significantly had higher education attainment (94%) (p = 0,001), but they showed lower knowledge about the benefit of folic acid (30%) (p = 0,037). They were also less likely to consume folic acid before (36%) (p = 0,001). The consumption of folic acid during pregnancy was not sifnificantly different between women in downtown area and in coastal area (p = 0,059).

Conclusion Folic acid was very important for fetus and infant. However, the knowledge was rarely known by women in downtown area. Moreover, they were also less likely to consume folic acid before and during pregnancy. Therefore, all health workers should disseminate the message and encouraging all women to consume folic acid before and during pregnancy.

Title: The wait is almost over Location: RSUD Budi Asih, Dewi Sartika, Jakarta Timur By : Alfiona Jesica Lekenila – Universitas Kristen Indonesia

This photo was taken in the afternoon. This photo is trying to potray the feelings while waiting for the new born baby. I choose usg picture as the main point is because this is how people keep an eye on their lovely baby and through this they can follow up the growth of the baby. As a background, there is one couple who is waiting for the baby to be born. They've been carrying it everywhere for a matter of months . It is the best time of every woman in the world for giving birth to their child. The maternal and child mortality is not a rare case in Indonesia. That is why it is important to educate a pregnant woman to always check their pregnancy with the right doctor and live a healthy life because they are the future generation. Educate a woman about pregancy is so important because when we educate a woman good enough , we educate a nation.

Contact Details Regional Chairperson AMSA-Indonesia Name : Elvira Lesmana Email : rcindonesia@amsa-international.org Phone : +6285811240637

A Simple Thing Can Affect Everything Arief Abdurrazaq Dharma - Hasanuddin University

Adequate amount of physical activity is important for pregnant women, one of the reason is because it is associated with reduced length of labor and delivery complications. The ideal physical activity should concern minimal risk of loss of balance and fetal trauma.(1) However, there are many contraindications for physical activity even in the simplest of things in daily life of pregnant women, such as motionless standing. Motionless standing is associated with decreased cardiac output. It can lead to fatigues and even fainting. It was observed that women who were on their feet for longer periods of standing, the fetal growth rates were considerably slower. It is important to know what to avoid for the health of the mothers because it will also affect the baby.

Treat the fetus with care, for the baby’s health won’t be rare.

References:

1. World Health Organization. WHO Recommendation on Antenatal Care for Positive Pregnancy Experience. 2016. Geneva: WHO Press.

Location: Preference Size of Print-out: 8R/10R

The First 1000 days: The Most Crucial Time of Mother and Baby Arief Abdurrazaq Dharma - Hasanuddin University

The baby in the picture is 7 days old. There are 993 days left for the baby to grow and develop into healthy human being and prevent much of the serious and irreparable damage with lasting effects that can transcend generations happens to the baby. What is so important about 1000 days of life then? It is the most crucial time for an infant where optimum health, growth, and neurodevelopment is constructed. So a healthy diet during pregnancy, breast milk during the first six months if possible, nutritious weaning foods and then a balanced diet during toddlerhood are vital for the child[1] The mother’s role is very pivotal during this period of time to ensure the nutrition for the baby is adequate.

Utilize every second, your baby’s health should be first, not the second.

References:

1. World Health Organization. Essential Nutrition Actions: Improving maternal, newborn, infant, and young child health and nutrition. 2013. Geneva: WHO Press.

Location: Preference Size of Print-out: 8R/10R

Mother Sacrifice Dedy Budi Kurniawan - Universitas Brawijaya

Mrs. Yeni, an apple dealer in a rural area of Batu City taking care of her fussy son while selling some apples. Mrs.Yeni and her son is not registered in BPJS (National Health Insurance System) so that free health access is a difficult thing and her income is still lacking to fulfill their needs. For the delivery of her first child, Faris, it takes about 1-3 million rupiah for normal delivery and for her it’s quite expensive. And from her story we know that the health care accesibility is still difficult for people like her due to financial problem.

Financial problem for Health care services especially for Maternal and Neonatal Health is still a problem for low income population. To solve this problem, we need an effort to removing barrier to effective use of the system, such as those related to financial cost. With the limitation of the financial problem, we can improve the community welfare and actualize the Sustainable Development Goals (SDG).

Photo Detail Print size: 10 R Location : Kecamatan Bumiaji, Kota Batu, Jawa Timur Consent : As attached

Technical Data Fujifilm XM-1, ISO 400, 1/75 sec, f/4.5

WHO’S EXCITED ?

Dewinsya Medisujiannisa MS Idris AMSA-Universitas Muslim Indonesia , Makassar ,Sulawesi Selatan , Indonesia dewinsyamedi.dr@gmail.com / +6281299090725

Photo details : Print size

: 8x10 inch

Location

: RSIA Sitti Khadijah Makassar , Sulawesi Selatan – Indonesia

Description & Background : Antenatal care is government program as part of efforts to reduce maternal mortality.

Maternal mortality still remains as a major problem in health sector, especially in developing countries, including Indonesia. K1 and K4 coverage continues to decline does not maintain the target has been achieved means that there are still many pregnant women are less regular antenatal. 1 Last year, an estimated 303 000 women died from pregnancy-related causes, 2.7 million babies died during the first 28 days of life and 2.6 million babies were stillborn. Quality health care during pregnancy and childbirth can prevent many of these deaths, yet globally only 64% of women receive antenatal (prenatal) care four or more times throughout their pregnancy.2 This photograph shows woman who was 9 months pregnant attend for the last antenatal care check, she just informed that she’ll delivery the baby in next few days. She was excited and happy at the same time,knowing that for a few days she’ll get to see her baby. Antenatal care is a critical opportunity for health providers to deliver care, support and information to pregnant women. This includes promoting a healthy lifestyle, including good nutrition; detecting and preventing diseases; providing family planning counselling and supporting women who may be experiencing intimate partner violence.2

References:

1.

http://apps.who.int/iris/bitstream/10665/250796/1/9789241549912-eng.pdf

2.

http://apps.who.int/iris/bitstream/10665/250800/1/WHO-RHR-16.12-eng.pdf

3.

http://www.who.int/mediacentre/news/releases/2016/antenatal-care-guidelines/en/

37 Weeks of Pregnancy Dyane Puspa Pertiwi Brawijaya University, Malang, Indonesia

Photo details: Print size

: 3” x 2”

Location

: Jalan Lembang 2D Malang

Consent

: As attached

Description: This is a picture of Mrs. Yeni who was waiting for her childbirth. Mrs. Yeni said that her husband and her family has always been supportive of her pregnancy since she was declared pregnant.

Mrs. Yeni was grateful that her husband has always warn her and support her in every step of her journey to maternity. Whenever she had cramps, when she felt tired, when she had trouble breathing, and when she couldn’t sleep at night, her husband always stayed by her side and help her.

Support from family and husband holds an important role during pregnancy. When mothers feel comfortable and safe, the baby will feel the same way. This condition will further help the mother during childbirth and breastfeeding. Only 15% of Indonesian mothers who give their babies breastmilk and Indonesia is ranked 30 from 33 countries in Asia on this case. If breastfeeding is low, there will be an impact on babies nutrition health status. The lack of education, information, facilities, advocation and protection for mothers during their breastfeeding period will hinder the 6th months of exclussive breastfeeding program.

References: 1. http://www.who.int/maternal_child_adolescent/topics/newborn/nutrition/breastfeeding/en/ 2. https://www.ncbi.nlm.nih.gov/pubmed/20169987 3. http://lifestyle.kompas.com/read/2011/10/27/07305724/kesadaran.asi.eksklusif.masih.rendah Note: Technical data: Canon EOS 500D, ISO-1600, f/3.5, speed 1/15s

Mother’s Hug Andi Muh. Firshan Makbul Hasanuddin University, Makassar, Indonesia

Photo details :

Location : Pasar Terong, Bontoala Street, Makassar, Sulawesi Selatan A baby named Naila just woke up from her nap time, so her mother decided to take her an afternoon stroll. This picture was taken when they were about to go out of the house and they took a pose by the door. Naila's mother is carrying her daughter while embracing her with love and affection.

Babies as young as two months know when they are about to be picked up and stiffen their body in preparation, according to new research. Research suggests, and perinatal educators experience, that misunderstanding newborn behavior can undermine a new parent's confidence, decrease breastfeeding success, interfere with bonding, and even contribute to neglect and abuse. When children are deprived of physical contact, their bodies stop growing despite normal intake of nutrients. These children suffer from failure-to-thrive. This growth deficiency can be improved when nurturing touches and hugs are provided.

Hugging triggers the release of oxytocin, also known as the love hormone. This feel-good hormone has many important effects on our bodies. One of them is growth stimulation. Studies show that hugging can instantly boost the level of oxytocin. When oxytocin is increased, several growth hormones, such as insulin- like growth factor-I (IGF-1) and nerve growth factor (NGF), are increased as well. The nurturing touch of a hug can enhance a child’s growth.

Giving hugs can help parents begin the adventure of parenthood with increased confidence, knowledge, and passion for their new baby.

References :

1. https://www.parentingforbrain.com/children-hugging/ 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2409163/

Technical Data : Sony A7, ISO 64, Shutter Speed 1/100, f/1,8

Safe Motherhood For The Greater Good Andi Muh. Firshan Makbul Hasanuddin University, Makassar, Indonesia

Photo details : Location : Pasar Terong, Bontoala Street, Makassar, Sulawesi Selatan This picture of a single father taking care of his two kids looks lovely but surely is missing something,or to be precise-it is missing someone. A mother is left out of the picture, quiet literally.

Everyday, 800 women die from preventable causes related to pregnancy and childbirth. 99% of deaths occur in developing countries just like Indonesia. The effects of maternal loss also affect the children prospective survival, and the inability of one or both parents to care for their children due to death, illness, divorce or separation increases the risk of death of their children. Maternal health, education, socioeconomic status, fertility behavior, environmental health conditions, nutritional status and infant feeding, and the use of health services play an important role in the risk of death of their children.

Efforts to achieve Millennium Development Goals no. 4 to reduce child mortality under 5 years in developing countries by two-thirds by 2015 should include promoting women's health and education.

Therefore is expected to be able to decrease the number of morbidity and mortality of mothers.

Any means to create a safe motherhood should be taken into consideration, for a greater future ahead.

References :

1.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501914/

2.

http://family.jrank.org/pages/1574/Single-Parent-Families-Demographic-Trends.html

Technical Data : Sony A7, ISO 64, Shutter Speed 1/100, f/1,8

Mental Health on Maternity

UPN Veteran Jakarta, Indonesia Author: Geulissa Addini Abidin

Photo was taken in a maternal clinic at Cakung, North Jakarta.

Pregnancy should be the one of the happiest moments in a woman's life. Feeling anxious and confused during pregnancy is a natural thing. But for many women the period of pregnancy is a confusing, frightening, stressful, and even depressed period. The source of stress may increase a person's risk for mental health problems, such as depression, panic disorder, obsessive-compulsive disorder or OCD, dietary disorders, bipolar disorder and even worst schizophrenia, and psychotic disorders. The risk is also much higher if the pregnant women have a history of serious mental health disorders before.

According to WHO research, about 10% of pregnant women and 13% of women who have just given birth experience a mental disorder, especially depression during pregnancy. In developing countries, such as Indonesia, even higher, it can reached 15.6% during pregnancy and 19.8% after childbirth. In some cases, the suffering of the mother may be so severe that they may even commit suicide. In some cases, the mother also can’t run their role as a mom. And as a result, the growth and development of the children becomes disrupted.

This is why it is so important to maintain a mother's health during her pregnancy. In addition to giving enough nutrition, pregnant women also need keep themselves away from stress with exercise regular checkup during pregnancy, and of course being happy.

Contact details of Regional Chairperson Elvira Lesmana rcindonesia@amsa-international.org +6285811240637

Readiness As A Newbie Maternal Isti Novitasari Brawijaya University, Malang, Indonesia

Description & Explanation:

In this photograph, there is a newbie mother who slowly try to holds her baby boy for the first time after a several hours of labor. She still looks tired but a lso excited and happy as we can see through her warm gazes toward her newborn baby. She finally can touches The Gift from God who had been growing inside her and she had been waiting for his presence to welcome him in this wonderful world. Surely, for her first son, she always wants everything to be perfect, safe and sound as if she wants to shout to the whole world that no one ever can hurt him.

In Indonesia, one from developing country, neonatal mortality is typically attributed to one of three major causes that crucial to understand that many of these deaths are either caused by one of the maternal conditions just described or are preventable by a maternal treatment. For example, neonatal deaths due to syphilis are preventable by maternal screening and treatment, and neonatal tetanus is preventable by maternal immunization. The little things that can actually be easily done but become bad if not done, such as educating newbie mother to always maintain good health before pregnancy until the baby is born.

Referrences: https://www.ncbi.nlm.nih.gov/books/NBK201704/#sec_0031 Details of Photo: Location

: RSIA Melati Husada, Malang, Indonesia

Size of Photo

: 8 x 12 inch

Consent

: As attached

Techincal Data

: Canon EOS 650D, ISO 5000, Shutter speed 1/50 sec, f/5

Title

: Try for their best

Location

: This foto was taken in Budhi Asih Hospital East Jakarta.

By

: Karina Yesika Manalu – Universitas Kristen Indonesia

Description of the Background

This is the situation around the birth room, as you can see a mother standing by her husband. Her husband was tying up her hair as she can’t tie up her hair by herself. The mother was at the end period of her pregnancy.

The second mother was sitting on the floor, trying to calm her crying son. As she was tying up her hair, her sister was holding her infusion. Then 5 minutes later, her husband came and picked their son up.

This photo is trying to portray that the mothers are trying their best to prepare for the birth of their child. So before they go into labour, they come to the hospital to check the well-being of their child every month. They want their child to be safe and healthy until the child is born.

So, it’s very important for the mothers to keep their health and wellness because their health is their childs health too.

Contact Details Regional Chairperson AMSA-Indonesia Name : Elvira Lesmana Email : rcindonesia@amsa-international.org Phone : +6285811240637

Teaching a Mother, Raising a Generation Kevin Luke, AMSA-University of Airlangga, Indonesia,

Children has important role for a country, they hold the nation’s future in their hands.

However, maternal and child have been major problem in Indonesia. According to Health Department of Indonesia (2016), children (0-59 months) mortality in 2015 reached 26,29 deaths per 1.000 live birth. Although, Millennium Development Goals target had been reached (26,29 vs 32 deaths per 100.000), children’ nutrition remains a major problem. Only 55,7% babies got breastfed and 55,7% children malnourished. Buku Kesehatan Ibu dan Anak (KIA) is a pregnancy-child development guidance book, made by government to increase maternal and child health in Indonesia. One of its program is doing at least four times antenatal care during their pregnancy and postnatal care, including child’ development and growth surveillance, breastfeeding and mother’ nutrition education, and immunization. Unfortunately, many mothers are still unaware of this program.

Thus, as a medical student, we support government’ program by educating and raising awareness about antenatal and postnatal care’ importance. We hoped that many mothers will realize and start doing antenatal-postnatal care. Through this photo, we want to motivate other medical students, especially those in developing countries to participate in educating mother directly about their pregnancy-child development. Because a medical learning is not only about studying with books, but also reaching the society directly to raisa a holistically better generation. Brigham Young once said ‘… You educate a woman, you educate a generation’. *this photo was taken at a small alley in Surabaya, 8 October 2017 with 70D DSLR Canon.

Reference: Kementerian Kesehatan RI, 2016, Profil Kesehatan Indonesia, Jakarta : Kementerian Kesehatan Republik Indonesia. [Available at http://www.depkes.go.id/resources/download/pusdatin/profilkesehatan-indonesia/profil-kesehatan-Indonesia-2015.pdf]

Baby On The Lens Hasanuddin University, Indonesia Moh. Fauzan

"As a mother i should be happy, my little blue eyes angel is sound asleep. Her face shines bright just like an angel. I hshould’ve approached her, but instead i did the opposite. All i wanted to do was stay away from and even run from the reality that i am now a mother". By Raidha Athira

Having a baby is supposed to be a feeling that feels you with joy, but some mothers don’t feel this way when their baby is born.“Baby blues syndrome” also known as postpartum blues or postpartum distress syndrome is a condition where the mothers feel depressed after they’ve given birth.

Almost 50% of mothers experience the baby blues syndrome. In addition to hormones, fatigue from caring from a newborn can be a cause of baby blues syndrome. Changes in lifestyle by the mother after giving birth can also cause the mother to feel depressed and show anxiety also fear that she is unable to care and raise her children well.

Many of our societies have little understanding of this. In addition to doctors, the process of curing the baby blues syndrome also requires love and support from her family members. The role of the husband is to keep the attention and focus of his postpartum wives so she knows that she’s not alone in overcoming this syndrome.

Location: Cahaya Medika Birth Clinic Preference Printed Size: 8/10R

FIRST TOUCH

By: Nadifa Kartika Dewi

University : Universitas Pembangunan Nasional “Veteran” Jakarta Location : Pondok Bersalin “SALMA” in Magelang Municipality Print size : 12” x 8”

Early initiation of breastfeeding is a procedure which the baby is placed to the mother breast within an hour after birth. This first skin-to-skin contact between the baby and the mother is vital because it can regulate the baby’s temperature, maintain the heartbeat, respiratory and also protect the mother’s health by reducing the risk of postpartum hemorrhage. It appears that this step let the baby to interact more with their mother and cry less. In this initial step, the baby will show the ability to “breast crawl” and this process helps to initiate early breastfeeding and increases the likelihood of exclusive breastfeeding for one to four months of life as well as the overall duration of breastfeeding.

Immediate skin-to-skin contact and early initiation of breastfeeding is key to newborn survival and quality care, it is the foundation for optimal breastfeeding until the child is six months old.

The newborn first absorb colostrum (first milk) that is rich in nutrients and antibodies and that is all the baby needs in the first few days of life. Feeding colostrum also stimulate the mother to produce more breast milk. Breast milk provides all the nutrient and water that the infant needs for the first six months, while protecting infants against diseases.

Optimal breastfeeding of children under two years of age has the potential to prevent 800.000 deaths of children under five every years. This is simple method yet very important for the baby’s future and mother health.

I didn’t Choose to be Premature Priscilla Christina Natan Brawijaya University, Malang, Indonesia

Prematurity is a term for the broad category of neonates born at less than 37 weeks' gestation. This baby, name Ahmad, he didn’t choose to be premature but he has to survive with immature organs which are not ready yet to be exposed by the environment. Many survivors face a lifetime of disability, including learning disabilities and visual and hearing problems. Globally, preterm birth is the leading cause of neonatal mortality and the most common reason for antenatal hospitalization.

Common causes of preterm birth include multiple pregnancies, infections and chronic conditions such as diabetes and high blood pressure. And as a medical student, we can prevent this from happening by our promotive and preventive educations to the pregnant woman, also give a proper care for premature babies to prevent mortality and morbidity. More than three-quarters of premature babies can be saved with feasible, cost-effective care, e.g. essential care during child birth and in the postnatal period for every mother and baby, provision of antenatal steroid injections (given to pregnant women at risk of preterm labour and under set criteria to strengthen the babies’ lungs) and antibiotics to treat newborn infections.

Preference print size : 10R Location: Parking lot RSSA (RSUD Saiful Anwar) Malang Consent: Attached

References: https://emedicine.medscape.com/article/975909overview

https://data.unicef.org/wp-content/uploads/country_profiles/Indonesia/country%20profile_IDN.pdf

The Importance of Early Breastfeeding Initiation (IMD) Hasanuddin University, Indonesia Sausan Maulida

This photo is a simple explanation on how important Early Breastfeeding Initiation (IMD) after birth. Early Breastfeeding Initiation (IMD) is an activity that initiates skin to skin contact between the mother and her baby. This procedure is recommended to be done as soon as possible. After baby’s umbilical cord has been cut and drained, the baby will be placed on the mother's breast. IMD's goal are to reduce infant and maternal mortality, stimulate the exclusive breastfeeding program and also strengthens the bond between mother and child. According to Makassar public health records, IMD has shown positive progress on local hospitals.

Preference of the photo print size: 10R Location where photograph was taken: Siti. Fatimah Hospital (Makassar, South Sulawesi)

Caring Mom, Healthy Me Authors: Donna Shandra Siswaty Ezra Basaria Giovany Eriqha Cecilya Marthing Faculty of Medicine, Trisakti University, Jakarta, Indonesia

BACKGROUND Indonesia is a developing country and the fourth largest country in terms of population size that has a capital city named Jakarta with the population about 10.177.924 (2015).(1) Living in the capital city with a lot of economic competition makes a lot of people, not only men, but also women and even pregnant women push their self to work really hard as for them can provide their necessity and have a proper life.

Within that conditions, the maternal mortality rate has been high over the past decade despite that they have already done efforts to improve qualiy of maternal and neonatal health which is about 228 in 100.000 birth, while for neonatal mortality is about 32 in 1000 birth in Indonesia and about 15 in 1000 birth in Jakarta._(1-2) Besides, due the dynamic nature of lifestyle, modern food habits and nutrition, there is a need to update our limited knowledge and understanding of maternal lifestyle and nutritional status and their impact on maternal and neonatal health outcomes. During pregnancy, it is essential that the mother’s diet contains adequate nutrients and energy at each stage to allow proper fetal growth and to maintain her own health.

Food and beverages, from our sources, there are some foods and beverages that are not healthy for pregnant woman, for example, methylmercury through tuna, polychlorinated biphenyls through salmon consumption, bisphenol A through canned goods, dibromoaceticacids containing tap water, caffeine containing beverages, and alcohol containing beverages during pregnancies. Eating high sugar sweet desserts and high fat and salt fast foods more than once a week are also unhealthy.(3)

Pregnant women are also advised to engage in appropriate levels of physical activity. At least 150min of moderate intensity activity (classified as 3 to 5 metabolic equivalent tasks) per week is recommended for pregnant women without medical problems throughout pregnancy to minimize detrimental health risks.(4) Previous studies have found that physically active women report improved physical stamina and mood as well as reduced rates of nausea, fatigue and stress. Low levels of physical activity are known to result in excessive gestational weight gain and obesity, where as maternal obesity increases health risks for mother and baby such as preeclampsia, gestational diabetes mellitus, hypertension disorders, delivery by caesarean section and stillbirth.

Findings from recent studies have also suggested that maternal sleep position may be a risk factor for stillbirth.(5) It has long been recognized that posture in late pregnancy can have a profound effect on maternal hemodynamics. Indeed, over half of the most important risk factors for stillbirth, such as maternal hypertension, gestational diabetes, and fetal growth restriction, have been shown to be associated with maternal sleep disruption WHO’s new antenatal care model increases the number of contacts a pregnant woman has with health providers throughout her pregnancy from four to eight. Recent evidence indicates that a higher frequency of a neonatal contacts by women with the health system is associated with a reduced likelihood of stillbirths. This is because of the increased opportunities to detect and manage potential problems. A minimum of eight contacts for antenatal care can reduce perinatal deaths by up to 8 per 1000 births when compared to a minimum of four visits.

PROPOSED POLICY Based on that prevalence and facts above, this conditions become our concerns about their daily life as a pregnant women who choose to still working that may increase the risk of that conditions. Along this video, we would like to share some simple and useful aspects for pregnant women to maintain moms’ and babies’ health including food and beverages, lifestyle, exercise, and giving care with the result will lead to strong bond between moms’ and babies, and also healthy mom that will giving birth to a healthy baby either.

During our journey on making this video and directly observing Jakarta’s current conditions, we would also like to present some advices may be applied by the government that can decreased maternal and neonatal mortality, as follows:

1.

Priority seats for pregnant women in public transportation should not be occupied by non-pregnant women.

2.

Waiting seats and special lanes for pregnant women while queueing in public transportation.

3.

Escalate the publication and promotion of maternal and neonatal health to public.

CONCLUSION In spite of how busy they are as pregnant women who choose to still working, they are obligated to take care of their self and pay a lot of attention to their baby by doing simple and useful aspects in daily life. In order to raised a good maternal and neonatal health, government need to interfere in public policy such as public transportation and education.

REFRENCES 1.

Profil Kesehatan Indonesia Tahun 2015. Kementrian Kesehatan Republik Indonesia 2016, accessed on October

26th

,

2017,

http://www.depkes.go.id/resources/download/pusdatin/profil-kesehatan-

indonesia/profil-kesehatan-Indonesia-2015.pdf 2.

Kesehatan Ibu dan Anak. Ringkasan Kajian UNICEF Indonesia, accessed on October 26 th, 2017, https://www.unicef.org/indonesia/id/A5_-_B_Ringkasan_Kajian_Kesehatan_REV.pdf

3.

Santiago SE, Park GH, Hauffman KJ. Consumption habits of pregnant women and implications for developmental biology: a survey of predominantly Hispanic women in California. Nutrition Journal.

2013; 12(91). Availabe from: https://nutritionj.biomedcentral.com/track/pdf/10.1186/1475-2891-1291?site=nutritionj.biomedcentral.com

4.

Tang L, Pan X, Lee AH, Binns CW, Yang C, Sun X. Maternal lifestyle and nutritional status in relation to pregnancy and infant health outcomes in Western China: protocol for a prospective cohort study. l.

BMJ

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6).

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resources.perpusnas.go.id:2171/docview/1911075892/fulltextPDF/F930128B8DB94DFBPQ/1?accou ntid=25704 5.

O’Brien LM, Warland J. Maternal sleep position: what do we know where do we go?. BMC Pregnancy Childbirth.

2015;

15

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1):

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4402690/pdf/1471-2393-15-S1-A4.pdf 6.

Pregnant women must be able to access the right care at the right time, says WHO. WHO Media Centre,

accessed

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October

28th

,

2017,

http://www.who.int/mediacentre/news/releases/2016/antenatal-care-guidelines/en/ 7.

Bryant A. Risk for Stillbirth is Lower Amonng Pregnant Women Who Sleep on Their Left Sides.

NEJM. 2011. Available from: https://search.proquest.com/docview/1284127669?accountid=25704

8.

Mastnak W. Perinatal Music Therapy and Antenatal Music Classes: Principles, Mechanisms, and Benefits.

J

Perinat

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25(3).

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resources.perpusnas.go.id:2171/docview/1806217732/fulltextPDF/7E04EE461F004BA6PQ/1?accou ntid=25704

APPENDIX

Contact details of Regional Chairperson: Elvira Lesmana •

rcindonesia@amsa-international.org

•

+6285811240637

Joint Effort by Healthcare System, Healthcare Personnel and Pregnant Individuals in Preventing Maternal Mortality

Clara Menna, Fianti Ratna Dewi, Gabriella Anindyah, Priscilla Aya Maheswari Subroto Universitas Indonesia Indonesia

Introduction

Current Status Maternal mortality continues to be the number one overlooked problem in the world by both physicians and the government, especially in developing countries. According to World Health Organization, 99% of maternal deaths occur in developing countries (1), a feat that is no exception for Indonesia, having a maternal mortality rate as high as 305 deaths per 100,000 live births in 2015 (2). Although this is not an updated number (as the next survey will only be held throughout 2017), this has shown that Indonesia had failed one of United Nations’ Millennium Development Goals of 102 deaths per 100,000 live births in 2015. Not only does this reflect Indonesia’s healthcare status, but also underlies other problems in Indonesia.

The impact of high maternal mortality rate in Indonesia is seen in the increase of burden held by the Indonesian government. This includes the high number of orphans in Indonesia reaching 3.2 million people in 2013 according to a comprehensive research by Yatim Mandiri. This correlates to Indonesia’s high maternal mortality rate, as more dying mothers mean that more children are born without a mother. This can further impact the upbringing quality of Indonesian children, whom without a mother lack a certain aspect in their lives that can affect their individuals, with problems such as greater criminal rates and relative poverty rate lingering at 11.1% in 2015. (3)

Context

Indonesia’s Ministry of Health stated that in 2013, the causes of maternal mortality includes postpartum haemorrhage (30.3%), hypertension (27.1%), infection (7.3%) and others (35.5%)(4).

Two major etiologies of maternal mortality are considered emergency situations during labour. In Indonesia and other developing countries, many cases of delivery are located in primary health facilities, assisted by physicians or midwives. Not all of these medical personnels have successfully done the right treatment for emergency situations, even though algorithms have been made(5).

Moreover, patients with complicated delivery that requires adequate facility that is not provided in the primary health care must be referred to a nearby hospital. In many cases, hospitals are fully occupied that these patients are not treated instantly. Patients will then be left untreated and possess greater risks of death. To overcome this, medical personnel’s competency needs to be improved and hospital referral systems must be optimized.

In addition to the role of health care in reducing maternal mortality, pregnant women shall also play important roles in keeping good health of their pregnancy by increasing their awareness of symptoms regarding possible labour complications. Therefore, there needs to be a joint effort from both healthcare system and pregnant individuals to reduce maternal mortality due to labour complications.

Key Objectives & Solutions This white paper highlights the key issues of high maternal mortality rate - prevention by joint effort of healthcare system, healthcare personnel, and pregnant individuals. The objectives proposed in this white paper are, ●

Objective 1: Improving maternal health during pregnancy to prevent possible complications that can lead to increased mortality risk during childbirth

●

Objective 2: Improving maternal care during childbirth

Objective 1 : Improving maternal health during pregnancy to prevent possible complications that can lead to increased mortality risk during childbirth

●

Increasing mothers’ awareness of possible complications

The Problem Antenatal care is recommended for pregnant women in providing regular check ups and to prevent potential health problems during pregnancy. Mothers who attend for antenatal care are made aware of their condition, but mothers who don’t become clueless about their health condition. For instance, a woman who never goes to antenatal care suddenly feels headache, nausea, and keeps on vomiting.

She finally goes to a healthcare facility to check her condition. She has high blood pressure and was diagnosed of eclampsia. This stage of detection is already too late and can cause higher risk of mortality during labour. A condition as such could have been prevented, but many mothers’ lack of awareness and compliance to go for antenatal care put them at risk of labour complications. With support from Institution of Social Insurance Administrator (Badan Penyelenggara Jaminan Sosial) in providing health insurance for Indonesian, healthcare is more readily available to people and antenatal visits have increased. However, in rural areas in Indonesia, such as Papua, West Papua, East Nusa Tenggara, the coverage of antenatal visits is still low, approximately only 50-60% of pregnant women (6).

Antenatal visits correlates to a decline in maternal mortality rate in Indonesia by monitoring health condition of pregnant women(10). However, some pregnancy complications might show symptoms that mimic the physiologic changes in pregnancy, such as headache, nausea, and vomiting. When experiencing this, mothers tend to be ignorant and refuse to consult a healthcare personnel. Mostly, only the exacerbation of symptoms will bring them to healthcare facilities, thus they could be diagnosed during the late phase of disease in pregnancy. This problem of late detection is again due to the lack of awareness of pregnant women regarding symptoms of pregnancy complications. Thus, this can further causes high maternal mortality during childbirth despite of regular antenatal visits(7).

Recommendation To further raise Indonesian mothers’ awareness of their health during pregnancy, we propose a simple, yet effective, checklist that highlights the symptoms of possible pregnancy complications.

This checklist is to be installed on large banners and billboards, as well as printed on leaflets and

posters in areas still lacking antenatal visits. The checklist content includes symptoms along with possible outcomes of pregnancy complications, which are its impacts to maternal and neonatal health and mortality.

Objective 2 : Improving maternal care during childbirth

●

Improving efficacy of referrals during emergency cases that could lead to maternal death

The Problem There are many problems associated with health-care system in Indonesia. For example, 29.6% of all births occur in homes and assisted by midwives, and are not fully equipped for a wide range of probable complications(8). Births that occur outside hospitals will eventually be referred to nearby hospitals, but many rural areas in Indonesia lack healthcare facilities that are easy to reach during emergency cases. Moreover, unlike in big cities of Indonesia, these facilities are not properly distributed, thus each facility can hold the burden of a very large area. This causes many of these healthcare facilities to be overcrowded with patients and unable to tend to all patients’ needs in time.

Furthermore, healthcare facilities in rural areas also lack human resources, equipments, and even electricity. These facilities are also harder to access due to further distance and difficulty in transportation(9). As a result of these problems, sometimes hospitals run out of intensive care units (ICUs) or operating rooms (ORs) and cannot treat patients accordingly. In some cases, in crowded hospitals (also happening in big cities as Indonesia’s population is very dense in these areas), patients have to wait a long time to be treated inside ORs. On top of that, integration of information is also problematic, as there are lots of overlapping and duplication of datas collected(10). The periodic collection of datas also makes most health-care personnels unaware of incidents happening in neighboring hospitals. In conclusion, Indonesia’s problems regarding the country’s healthcare system includes overcrowded hospitals, lack of resources, inaccessible facilities and lack of integrated information. These problems further impacts in the increase of maternal mortality.

Recommendation From the numerous problems stated above, we would like to propose a solution to improve the efficiency of healthcare facilities. Technological advancements can elevate referring problems by combining and analysing datas from neighboring hospitals. Based on Indonesia’s Ministry of Health Regulations No. 82 Year 2013 regarding Information System in Hospitals (SIM)(11), each hospital have implemented an integrated computer-based information system to record real time datas.

However, SIMs among hospitals is not integrated, since every hospital has their own system.

Therefore, we propose the creation of HIP, which stands for Healthcare Integration Programme.

HIP will fill the gap between systems from different hospitals, and make interhospital cross referencing possible. The program will collect datas from SIMs in different hospitals and analyse each data real time. Hospitals that need to be refer patients to a different hospital will ask for a recommendation, and HIP will calculate the distance and travel time between healthcare facilities, available operation rooms and hospital traffic, and finally come up with choices of hospitals that are most likely available to treat the patients.

●

Improving competency of healthcare personnel especially in primary health care facilities

The Problem Aside from pregnant mothers’ awareness and compliance, medical workers in local healthcare services must be able to provide adequate management for possible obstacle regarding maternal and neonatal health. Medical workers’ competency is one of the key factor to the success of case handling. Therefore, Indonesia’s Ministry of Research, Technology and Higher Educations (KEMENRISTEKDIKTI) along with Ministry of Health cooperates with other entities, such as The Indonesian Medical Council (Konsil Kedokteran Indonesia) and the Indonesian Health Personnel Assembly (Majelis Tenaga Kesehatan Indonesia), sets out the standard competency for medical workers’ license, including physicians, dentists, midwifes and nurses(12-13). However, there is not enough periodic follow-up for licensed workers. Since health-care personnel does not encounter all types of cases in their area, after a period of time, knowledge or skills unpracticed will fade(14).

Moreover, integration of health information system and reports is inadequate. This results in a decentralized information system which made monitoring and enforcement more difficult(13).

Therefore, regular competency assessment of medical workers is required to maintain competent licensed healthcare providers.

Recommendations Focusing on maternal health, we propose a simple method to appraise licensed general practitioners and midwives’ proficiency by annually performing an online-based evaluation test, called Evaluation and Training (E&T). A qualified certificated team must be selected by concerned authority to design a multiple-choice-questions (MCQ) by computer based test according to the specific department. The results from this examination will be used as a standard criterion to determine which local healthcare provider needs evaluation. Medical personnel that does not meet the standard of qualification will be marked. This indicate that healthcare providers in the specific area needs further training.

Materials and curriculum will be arranged beforehand by incorporated teams and agreed upon.

Qualified physicians and specialists, especially from the obstetrics and gynecology department will be sent to areas with most marks. Each team in charge of the specified area is appointed as coaches and must train the local medical workers. This will provide periodic improvement and maintenance for medical workers’ competency.

Previously marked medical workers, along with those who met the standard qualification will again be tested in the following year. This method can help the government and implicated organizations observe the local medical workers’ progress annually. Furthermore, ‘incompetent’ personnel will annually be trained and monitored, and may hopefully improve their skills to further ameliorate maternal health in their areas.

Conclusion Joint effort by Healthcare system, healthcare personnel and pregnant individuals is needed to improve maternal mortality in Indonesia. We propose some recommendations to meliorate each role.

Healthcare system interhospital reference can be achieved by HIP (Healthcare Integration Programme) -- a data analyser that can provide options for available referral hospitals. Secondly, healthcare personnel needs annual evaluations, and those who does not meet the standard qualification will be given trainings by certified personnel. This method can provide generalization for standard competence among nationwide healthcare personnel. Finally, pregnant individuals also need to be exceptionally aware of their own condition during pregnancy. Therefore, we provide a simple checklist to help raise mothers’ awareness of possible signs that may lead to maternal and neonatal mortality.

Bibliography

1. Maternal mortality [Internet]. World Health Organization. 2016 [cited 31 October 2017].

Available from: http://www.who.int/mediacentre/factsheets/fs348/en/ 2. Kementrian Kesehatan Republik Indonesia. Indonesia Health Statistics 2016. 2017. Jakarta: Kementrian Kesehatan Indonesia. P102.

3. Indonesia Overview [Internet]. The World Bank in Indonesia. 2017 [cited 31 October 2017].

Available from: http://www.worldbank.org/en/country/indonesia/overview

4. Pusat Data dan Informasi Kementrian Kesehatan RI. Info datin - Mother’s day [Internet].

2014 [cited 31 October 2017]. Available from: http://www.depkes.go.id/resources/download/pusdatin/infodatin/infodatin-ibu.pdf 5. Bakti Husada; Ikatan Dokter Indonesia. Panduan Praktik Klinis Bagi Dokter di Fasilitas Pelayanan Kesehatan Primer. 2014. P605-613.

6. Ministry of Health, Republic of Indonesia. Ministry of Health Republic of Indonesia Regulations No. 18 year 2017 Regarding the Execution of Competency Examination for Medical Personnel (Peraturan Menteri Kesehatan Republik Indonesia No. 18 tahun 2017 tentang Penyelenggaraan Uji Kompetensi Jabatan Fungsional Kesehatan).

7. General Medical Council. Skills fade: a review of the evidence that clinical and professional skills fade during time out of practice, and how skills fade may be measured or remediated: a literature review. 2014.

8. Badan Penelitian dan Pengembangan Kesehatan Kementrian Kesehatan RI. Riset Kesehatan Dasar 2013. 2013. Jakarta: Bakti Husada. P177.

9. Joint Committee on Reducing Maternal and Neonatal Mortality in Indonesia; Development, Security, and Cooperation; Policy and Global Affairs; National Research Council; Indonesian Academy of Sciences. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington (DC): National Academies Press (US); 2013.

10. Mahendradhata Y, Trisnantoro L, Listyadewi S, Soewondo P, Marthias T, Hrimurti P, and friends. The Republic of Indonesia Health System Review. Health Systems in Transition.

2017; 7(1).

11. Peraturan Menteri Kesehatan Republik Indonesia Nomor 82 Tahun 2013 Tentang Sistem Informasi Manajemen Rumah Sakit.

12. Indonesia Health Profile 2013. (2014). Jakarta: Ministry of Health Republic Indonesia.

P.260-262.

13. Mikrajab MA, Rachmawati T. Policy Analysis of Integrated Antenatal Care implementation at Public Health Centers in Blitar City. Buletin Penelitian Sistem Kesehatan. 2016; 19(1): 41-53.

14. Ratan Das, S. Eclapmsia: The Major Cause of Maternal Mortality in Eastern India. PubMed Central (PMC). 2017; 25(2): 111-116.

I Wish ...

Livia Difyanty Kristina Fianiyanti Maria Jessica Yaputri Nathania Christabella Sebelas Maret University

Background

Measles is a highly communicable disease, which is caused by a virus, and transmitted through coughing and sneezing. When someone is infected by the measles virus, 90% people who interact closely with them can also be infected, especially if they have not been vaccinated to the virus.

Rubella is an acute disease that frequently infects children and young people who are not immune enough. The main point of this public health

MR Immunization on children age 9 months to 15 years old with 95% coverage and equal distribution is expected to form a herd immunity, with the result that decreases the virus transmission to adults and protects the community on their reproductive age, particularly pregnant women.

Proposed Policy We propose a cooperation with the

campaign is the teratogenic effect, is rubella infects

government in the MR (Measles Rubella)

pregnant women in the first trimester. The

campaign program that has the goal of

teratogenic effect causing abortus, neonatal death or

elimination of measles and rubella / CRS

congenital rubella syndrome (CRS). Measles and

(Congenital Rubella Syndrome) control in

rubella are two of the public health problems which need effective preventive actions.

2020 through our video entitled "I Wish ...".

This video is expected to increase public

From 2010 to 2015, an estimated 23.164

awareness

measles cases and 30.463 rubella cases

immunization measles and rubella. With

occured in Indonesia. Around 0.2 per 1000

the increased coverage of measles and

newborn babies had Congenital Rubella

rubella vaccinations, the incidence of CRS

Syndrome (CRS), that is 979 new CRS

that can lead to neonatal disability and

cases in Indonesia.

death can be derived and eliminated.

of

the

importance

of

In the Global Vaccine Action Plan (GVAP), measles and rubella are targeted to be eliminated in the five regions of WHO in 2020. Along with GVAP, The Global Measles and Rubella Strategic Plan 20122020 consists of the strategy to attain a world, free of measles, rubella, and CRS. Indonesia has committed to eliminate measles and control rubella / CRS in 2020. Thus, a campaign concerning MR immunization is needed for 66.859.112 children age 9 months to 15 years old in Indonesia.

Chart 1. Measles and Rubella Estimated Cases in Indonesia from 2010-2015

Conclusion This video is expected to prevent and reduce the incidence of neonatal disability and death that is resulted by measles and rubella which attack pregnant women on their first trimester. The spread and transmission of rubella disease can be prevented by immunization. Measles and rubella immunization can be performed on children aged 9 months to 15 years and also on women before pregnancy. By 2017, the government has already conducted MR campaigns and will be implemented again in

2018.

Increased

coverage

of

immunization will suppress the spread of measles and rubella so as to prevent the occurrence of congenital defects and neonatal deaths.

References Subuh, Mohamad, dkk.(2017). Petunjuk Teknis

Kampanye

Imunisasi

Measles

Rubella (MR). Jakarta: Direktorat Jenderal Pencegahan dan Pengendalian Penyakit Kementrian Kesehatan RI.

THE FIRST 1000 DAYS OF LIFE

Authors :

Siti Zakiaturrahmah, Regina Mega Ayu P.S, Farraskya Andini, Thia Indriana

FAKULTAS KEDOKTERAN UNIVERSITAS JENDERAL ACHMAD YANI CIMAHI

Background In the implementation of health efforts, mothers and children are family members who need to get priority. Based on Indonesia Demographic and Health survey 2012, maternal mortality rate in Indonesia is still high that is equal to 359 per 100,000 live births. The 5th global MDGs (Millennium Development Goals) target is to reduce maternal mortality to 102 per 100,000 live births in 2015.1 Unfortunately, in West java there is around 823 mothers died during delivery per 950.000 live births.2 The common causes of maternal mortality are bleeding, preeclampsia, infections, and obstructed labor. These conditions also contribute to the three highest burden newborn conditions.

Child mortality is also a major problem in

Indonesia. Every three minutes in Indonesia, one child dies and every minute one woman dies during labor or due to pregnancy-related causes. Most children death during neonates (first month of life). The likelihood of children dying at different ages is 19 per thousand during the neonatal period, 15 per thousand at the age of 2 to 11 months and 10 per thousand from the age of one to five years.1 Preterm birth, severe infection, asphyxia, congenital abnormalities are the common cause of neonatal death.1 Therefore we bring up with the First 1000 days of life as our strategies to reduce maternal and neonatal mortality rate in order to develop gold generation in the future.

Health services for maternal and neonatal can prevent high mortality rates. In Indonesia, the neonatal mortality rate whose mothers receive antenatal care and delivery assisted by professionals is minimal than the mortality rate in neonatal whose mothers did not receive the services. Twenty five percent of rural mothers and eight percent of urban mothers never receive antenatal care or never visit antenatal care during pregnancy. Maternal assistance during pregnancy is thought to increase mother awareness of the importance of visits to antenatal care during pregnancy. In addition, maternal assistance until First 1000 Days of life thought to decrease mortality rate of mother and neonates.3

Proposed Policy Community based learning program called as First 1000 days of life program is a maternity facilitation program held in six districts at Cimahi, west java. Every student gets responsibility for one pregnant woman until the child birth and monitor the children’s growth and development up to 3 years old. Before home visits student get preliminary lecture to know the things to keep in mind during the visits. Every month the topic of home visits is different such as the importance of contraception, the benefits of antenatal care, etc. During home visits student will check about mother’s pregnancy with asking her conditions, measuring the blood pressure, body weight, temperature, Upper arm circumference and check the medical record in mother and children health book which contain all information about the pregnancy and child development. Students also share some knowledge about pregnancy to the mother for example like

the importance of consuming nutritious food during pregnancy. Sometimes student accompany mother to health service to check mother’s condition. Student must follow up the mother once a month and report the result to the supervisor in Focus Group Discussion (FGD) to discuss about the mother pregnancy. Every six month student will invite the mother for yoga and attend some workshop or symposium.

After the child was born, student will monitor the growth and development of the child with home visits once a month. During home visits student will check the mother and child’s condition base on mother and children health book and do some measurement. Student will measuring body weight and height and children’s head circumference after that check the result in world health organization (WHO) Growth and development curve. By this First 1000 days of life, not only the mother and her family who gets the benefits but also the student. The student gets more knowledge especially about maternal, delivery and child development, gets ability to communicate with wide society and gets more experience outside the classroom.

Conclusion Maternal and neonatal mortality is still high especially in west java. Through First 1000 days of life is expected to bring a lot of benefit not only for the student but also wide society especially in Cimahi, West Java. Increased mother knowledge about her pregnancy and her child for example visits health services regularly at least 4 times during pregnancy and brings her child to health services once a month until one year are the small steps to increase maternal and neonatal health.

References

1. Infodatin Pusat data dan informasi Kementrian Kesehatan RI. 2014. http://www.depkes.go.id/resources/download/pusdatin/infodatin/infodati n-ibu.pdf 2. Angka Kematian Ibu di Jawa Barat Tinggi. 2016. http://www.jabarprov.go.id/index.php/news/17978/2016/06/23/Angka-Kematian-IbuMelahirkan- di-Jabar-Tinggi 3. UNICEF Indonesia Rangkuman Kajian Kesehatan Ibu dan Anak.

2012. https://www.unicef.org/Indonesia

Authors : • Dzakiyyah Marsuqah N • Batara Caya Karim • Muh. Azhar Fawwas • Puteri P. Abigael Lagha

Institution : Hasanuddin University

MATERNAL MORTALITY Everyday, approximately 830 women die from preventable causes related to pregnancy and childbirth.

Maternal mortality is unacceptably high. About 830 women die from pregnancy- or childbirth-related complications around the world every day. It was estimated that in 2015, roughly 303.000 women died during and following pregnancy and childbirth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented.

Women die as a result of complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy and most are preventable or treatable. Other complications may exist before pregnancy but are worsened during pregnancy, especially if not managed as part of the woman’s care.

Reproductive, maternal, newborn and child of the four categories of the UHC coverage index. This category includes four coverage indicators : family planning, antenatal care (four visits the doctor or more) with skilled attendance of birth, full child immunization coverage, and health-seeking behavior for suspected child pneumonia.

Major coverage gaps for all four of these indicators persist in many countries, especially among disadvantaged populations.

The major complications that account for nearly 75% of all maternal deaths are:4 •

severe bleeding (mostly bleeding after childbirth), Severe bleeding after birth can kill a healthy woman within hours if she is unattended. Injecting oxytocin immediately after childbirth effectively reduces the risk of bleeding.

•

infections (usually after childbirth), Infection after childbirth can be eliminated if good hygiene is practiced and if early signs of infection are recognized and treated in a timely manner.

•

Hemorrhage

•

High blood pressure during pregnancy (pre-eclampsia and eclampsia)

•

Complications from delivery

•

Unsafe abortion

•

Obstructed labor The reminder are caused by or associated with diseases such as malaria, and AIDS/HIV during pregnancy.

Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. All women need access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth. Maternal health and newborn health are closely linked. It was estimated that approximately 2.7 million newborn babies died in 20155, and an additional 2.6 million are stillborn6. It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death for both the mother and the baby.

To avoid maternal deaths, it is also vital to prevent unwanted and too-early pregnancies. All women, including adolescents, need access to contraception, safe abortion services to the full extent of the law, and quality postabortion care.

POLICY PROPOSE The role of medical students to the maternal and neonatal health are to provide and give counseling to pregnant woman to always sufficient nutrition with healthy foods to prevent malnutrition birth and also to the woman 40 ages above given suggestion not to get pregnant again because it has a high risk to maternal death. The role of government in preventing maternal death and birth defect are to improve maternal and child health status and nutrition, improve disease control, improve access and quality of basic health care especially in underdeveloped areas, improve the responsiveness of the health system and many more.

CONCLUSION Maternal mortality is a serious problem but some of them are preventable and treatable it happens mostly because these women didn’t receive the proper care needed for their health issues. Giving a proper care for pregnant women can make a life and death difference for the mother and the baby and it’s only the government’s role we as medical student can start it by giving proper education for these women about keeping sufficient nutrition with healthy food. Together with the government we can save both the mother and their babies.

REFERENSI World

Health

Organization.

Maternal

Mortality.

2016

Retrieved

from

http://www.who.int/mediacentre/factsheets/fs348/en/ (30 October 2017, date last accessed) Journal of Public Health. Evidence-based practices to reduce maternal mortality: a systematic review.

2008 Retrieved from https://academic.oup.com/jpubhealth/article/31/1/26/1585456/Evidencebased-practices-to-reduce-maternal.

BioMed Central. Risk factors for maternal death and trends in maternal mortality in low- and middleincome countries: a prospective longitudinal cohort analysis. 2015 Retrieved from https://reproductivehealth-journal.biomedcentral.com/articles/10.1186/1742-4755-12-S2-S5.

Free Sex Amongst Teenager in Indonesia: A Threat on the Nation Maternal and Neonatal Health Muhamad Faza Soelaeman1, Brenda Christie1, Imam Rahadian Soleman1, Anthonius Yongko1 1

Faculty of Medicine, Universitas Indonesia

ABSTRACT One of the major health problem faced by Indonesia is maternal and neonatal health. Suprisingly, many of neonatal deaths and abortion are in the group age of below 20 years old women. Inspite many factors that could lead to such problem, free sex is one of the main and upstram reason. In teenage year, it could lead to unwanted pregnancy thus creating stress and increasing the risk of neonatal mortality and abortion. It could also cause STD thus increasing problem regarding maternal and neonatal health.

Despite the danger, there are no current consitution on inhibiting free sex and current programs available such as PKPR and Genre are not as effective. Therefore, we propose a solution, containing a prevention program called STOP (Standardized Teaching Of Preventing-Free-SEX) Program, strengthening and promoting available program, and collaborating with related institution, including national, international, and non-govermental organization.

Free Sex Amongst Teenager in Indonesia: A Threat on the Nation Maternal and Neonatal Health Muhamad Faza Soelaeman1, Brenda Christie1, Imam Rahadian Soleman1, Anthonius Yongko1 1

Faculty of Medicine, Universitas Indonesia

BACKGROUND Maternal and neonatal health is one of the major health problem faced by Indonesia. According to the Indonesia Demography and Health Survey, the number of maternal health in the nation are still pretty high. In 2012, it has caused around 359 deaths out of 100.000 birth, which is far from the Millenial Development Goals (MDGs) target by 2015 which is 102 deaths. The number of neonatal death are also

quiet high with 14 deaths of of 1,000 births. Among those deaths, the number of mortality is ranked 1st from mothers with the age of below 20 as seen in figure 1. From the data, it can be implied that the highest number of mortality among neonatus are from teenage mothers. This is an interesting fact as the survey also found that most teenager stated that the ideal age for marriage starts from after 20 years old. Other than neonatal mortality, teenage pregnancy could also lead into abortion. In fact, 8% of abortion cases come from women below 20 years of age and 33% of cases come from unmarried women. Therefore, there are several risk factors that could lead to such problem, and one of the main and upstream reason is free sex.1,2

Figure 1. Number of deaths classified by the age of the mother

Figure 2. Abortian data in Indonesia

Free sex, which has no official meaning could be implied as casual sex with different sex partners and or pre-martial sex, is currently becoming more common in the society, including the teenager. The

Indonesian Demography and Health Survey (SDKI) found that 4.5% and 14.6% of teenager between the age of 15-19 and 20-24 years old respectively has done pre-marriage sex in 2012, growing from 3.7% and 10.5% in 2007. This is due to several reason such as curiosity (57.5% male). According to the WHO, teenager is a population within the age of 10 to 19 years old which is added to 24 years old if referring to the Indonesia National Family Planning Coordinating Board (BKKPN). Teenage year is the periode of considerable growth and development physically, intellectually, and psychologically.

However, due to high level of sexual hormones, teenagers tend to have high curiosity level, eiger to seek adventure, and has the courage to take risks without proper consideration. These group also tend to follow their friends. If decision is taken without further deliberation, teenager would fall into high risk behavior and could have to bear the consequences including short and long term which include problem regarding physical and psychosocial health. Free sex could lead to unwanted pregnancy, creating stress thus increasing the risk of neonatal mortality and abortion.2-5 Free sex could lead people to sexually transmitted disease (STD), such as syphillis, gonorrhae, and HIV. According to the Minsitry of Health, more than 35% of people affected with AIDS are from the age of 15-29 years old. This means that the act of free sex has taken many years of productivity in many people. As much as 28.5% of the patients comes from the age of 30-39 years old. This means that they could get infected from when they were a teenager as HIV virus could only create AIDS after a few years. These people could make their decendant be infected as well thus creating a neonatal mortality as it has created more than 1% of neonatal death in Indonesia. Other STD could also be transmitted to neonatus, for example Syphillis. If a pregnant woman has Syphillis, it could lead to miscarriage and stillbirth which increase the risk of maternal and neonatal mortality.3,5 Seeing the danger caused by free sex, the government should have taken actions to prevent it creating problem. In the national consititution, there are no rules available on preventing free sex. The only rule regarding it is in KUHP Pasal 284 ayat (1) stating that a person would broke the rule if he/she had sex when they have a wife/husband or when their partner has a wife/partner. It should prevent the danger of free sex on adults, but it could not affect much on teenager. On the other hand, the government has programs regarding this problem for teenager, such as the Adolescent Health Care Program (PKPR) and Planned Generation (GenRe). However, those problems mainly focus on primary health care centers which could not reach as much as teenager as in other centers, such as the primary and secondary school. The education within the program are more likely to be a hit-and-run system done by officials only, thus it would not be sustainable enough.1

SOLUTION

Based on the problems facing Indonesia which is caused by the implementation of free sex in teenager, we

proposed

some

solutions

towards

the

issue,

which

include:

1. Creating the STOP Program (Standardized Teaching on Preventing-Free-Sex Program) which is a peer-to-peer based teaching program focusing on educating teenager on reproductive health with a curricullum that could make them able to teach their own friends, family, and relatives. It is created to make an hollistic approach on making teenager get educated about reproductive health which in hope could reduce maternal and neonatal death on those group of age. This program could be done by any medical student in Indonesia or even internationnally and individually or organizationally (for example by the Asian Medical Student Association (AMSA), Central for Indonesian Medical Students Activities (CIMSA), Ikatan Senat Mahasiswa Kedokteran Indonesia (ISMKI)). Hopefully, this program could be implemented in education institution, especially in Junior High School (SMP) and High School (SMA), starting from the School Health Unit (UKS) or into the curricullum itself.

2. Strengthening and promoting available programs for reproductive health education and free sex prevention such as: (1) PKPR, (2) GenRe, (3) Civic, Religion, and Social Education in Primary and Secondary School. As it has been explained before, these program actually has great potential on preventing free sex. Therefore, we as a society should strengthen and further promotes those programs so the effort that the government has created would not goes to waste.

3. Collaborating with national government organization such as the Ministry of Health, the Ministry of Child and Women Protection, and the Ministry of Education and Culture, international organization such as the World Health Organization (WHO), the Joint United Nation Programme on HIV/AIDS (UNAIDS), and the United Nation’s Children Fund (UNICEF), and non-govermental organizations (NGO) such as Independent Teenager Alliance, Hope for Teenage Mother (HTM), and etcera with the focus of: (1) education in reproductive health, (2) prevention of free sex in teenager, (3) education for maternal and neonatal health for pregnant teenager or teenage mom, and (4) creating a support group for teenager with reproductive, maternal and neonatal problem.

References: 1. Kementrian Kesehatan RI. Infodatin: Situasi Kesehatan reproduksi remaja. 2016 2. Kementrian Kesehatan RI. Infodatin: Situasi Kesehatan ibu. 2016 3. Kementrian Kesehatan RI. Infodatin: Situasi dan analisis HIV AIDS. 2016 4. Centers for Disease Control and Prevention. Sexually transmitted disease (internet). Atlanta: U.S Department of Health & Human Services; 2016. Available from: https://www.cdc.gov/std/default.htm

5. WHO Statistical Profile. Indonesia. 2015

A. Background

In 2010, 60 million people in the world had been infected with HIV. 90% of children with HIV infection exist in developing countries.4 In Indonesia, it is predicted that the number of HIV suspect will be exploded in the next 10-15 years. In the nation’s context, the prevalence of pregnant mother with HIV is 0,49% in 2016, and HIV on children tend to increase from 4361 cases in 2012 to 5565 cases in 2016. HIV is transmitted from mother by vertical transmission (e.g. transplacental, because infected lymphocytes is spread into the placenta), intrapartum transmission (because there is a lesion on baby skin or mucosa or the swallowing of mother’s blood during the delivery).1 Risk factors of antepartum infection is delivery pervaginal and premature ruptures of amnion. Postpartum infection is transmitted by breast milk (e.g. the age of breastfeeding baby, breastfeeding pattern, mother’s breast health, and lesion on baby’s mouth). 2

(During Pregnacny) (During Labor) (Postnatal – breasfeed)

(total risk)

This case is being worse especially because the low antenatal care obedience in pregnant woman, especially in rural area where the number of HIV/AIDS new cases also highly increasing. The standard of Indonesias’s government is pregnant woman should be done antenatal care in health center at least 8 times during pregnancy. In fact, most of woman still only do this 4 times. Fortunately, there are abundant midwifes spread across the country to do the antenatal visitation in pregnant women’ houses. However, to ask the pregnant women to do the HIV/AIDS screening is still a challenge and it is not the part of obligatory antenatal screening, but depends on the choice of the women. The health provider only can inform them and persuade them to take the screening.

Promoting the prevention of transmission of HIV in pregnancy issue is prominent because ASEAN and Kemenkes Republik Indonesia had set a target, that in 2030, we have to have zero discrimination, zero new infection, and zero death related to HIV/AIDS. 3 The most paramount cause of HIV is when the father had sexual intercourse with another woman, then the father got HIV but he kept the secret alone, after that the mother got transmitted, but she didn’t know anything about the virus. 5 The goal of this movie is to increase the awareness of mothers towards the prevalence of HIV in pregnancy. This video tells us that there is a child, born from HIV mother, but fortunately, the child didn’t get the HIV. The child was once thought that HIV is a horrible disease, it represents the negative stigma of society towards HIV. But then after the conflict resolved, she can ever look at HIV the same way again. In this video, her friend came to her, representing that people with HIV need our social support.

This video is wrapped with drama concept, style, and ambience so it will excite people, especially adolescent and productive age which like to watch with a story with mind-altering plot. This video is targetted to the common people.

B. Proposed Policy •

Promoting prevention of HIV and sex education from earlier age (e.g: using a condom, using a steril syringe, etc) to our children.

•

Giving education in school (especially junior high school until senior high school) about how to prevent transmission of HIV from the mother to the children, so they are aware to do the former screening.

•

Education about antenatal care priorly earlier so when a women got pregnant, she had alerted to do antenatal care.

•

Midwife had to be educated specifically, in order to be aware of antenatal care and its relation with HIV. In Indonesia, midwife tends to visit houses and get the labor done in the house. There’s a prominent risk factor if they still not aware, especially the transmission of HIV. From a decent antenatal care, we can prepare the mother to prepare a proper postnatal care for her children (e.g: antiretroviral consumption, the right period to give the breast milk, etc.).

F. Conclusion Promoting HIV in pregnancy issue is prominent because the prevalence of HIV in pregnancy is increased each year, nevertheless, ASEAN and Kemenkes Republik Indonesia had set a target, to get zero discrimination, zero new infection, and zero death related to HIV/AIDS. The goal of this movie is to increase the awareness of mothers towards the prevalence of HIV in pregnancy, wrapped with drama concept so it will be exciting.

G. Reference 1.

2.

3.

Indonesia Ministry Of Health. 2016. Integrated Biological and Behavioural Surveillance Survey.

Junnisa, Silva Dwinta and Wiyati, Putri Sekar and Wijayahadi, Noor (2015). Maternal and Neonatal Outcome in Labor of HIV/AIDS Woman with CD4 Analysis. Yogyakarta : Faculty of Medicine UGM ASEAN Good Practices and New Initiatives in HIV and AIDS. 2014

4. UNAIDS. Global Report: UNAIDS Report on the Global AIDS

Epidemic. 2010.

5. UNIFEM. Responding to Feminisation of AIDS: A Rapid Assessment on Spousal/Partner Transmission of AIDS and Sero-Discordant Couples in Indonesia, Lao PDR, and Thailand.

2009.

UNPLANNED PREGNANCY, UNPLANNED FUTURE

White Paper AMSA Hasanuddin University

MUHAMMAD REYHAN

(C11115511/AMSA-UNHAS)

AHMAD EZRA SALEH

(C11115383/AMSA-UNHAS)

AMILA SALIHA

(C11116046/AMSA-UNHAS)

NABILA ZHAVIRAH P. ARFIN

(C11116565/AMSA-UNHAS)

ASIAN MEDICAL STUDENTS’ ASSOCIATION INDONESIA (AMSA-Indonesia) 2017

BACKGROUND Determining one being’s health is contingent upon many factors including social and culture.

Cultural or even religious beliefs, educational background, environment, are examples of influences that contribute to social hazards. One of the main social hazard that is imperative to the world society is pregnancy in adolescent.[1] Therefore, it is the absolute international community’s obligation to eradicate one of the most common public health problem which is adolescent maternal morbidity and mortality in both developing and developed countries. According to World Health Organization (WHO), Adolescents who are 15-19 years of age are twice as likely to die during pregnancy or childbirth compared to woman over 20 years of age. Moreover, adolescents under 15 years of age are five times more likely to die during pregnancy or childbirth. This leads to the fact that the second cause of death for 15-19 year-old girls globally is complications during pregnancy and childbirth.[2] In many countries, women aged 20-24 years are likely to have been married before age 15.[3] The possibilities are leading to adolescent pregnancies, where the social understanding drive the girls to believe that they are ready to have children as knock on effect of their marital status, without significantly comprehending the health risks that they are going to through physically and mentally if they have a too early pregnancy. Rape culture is also one of the most urgent social hazards that leads to adolescent pregnancy such as what happens in South Africa, where 11-20% of teen pregnancies are reported as the result of rape.[4] Unplanned pregnancies are also one of contributing factors for health risks of maternal and neonatal health. The social judgments, emotional and mental burden, severe damage to the sexual and internal organs are what lead to unwanted behavioral patterns and health problems during pregnancy that can endanger the mother’s life and also the baby. The mishaps during pregnancy will make baby more likely to be born prematurely, do poorly in school, then drop and about 30% more likely to become teen parents themselves.[4] According to Badan Pusat Statistik Indonesia (State Statistical Office), on Survei Demografi dan Kesehatan Indonesia (Demographic and Health Survey of Indonesia), in 2012 it’s stated that adolescent pregnancies have 48 cases from 1000 pregnancies, that is increasing every year. [5] In Indonesia, the risk of death is also increased two until four times than women pregnant at age 20 – 30 years old as well as the risk of infant death for adolescent pregnancies are 30% higher, this can be caused by the hormonal turmoil faced by the adolescents thus risks like anemia, bleeding, abortus, etc. are easier to get.[6] There are a lot of contributing factors to this issue and vast majority of them are individual affair, such as knowledge, attitude and beliefs; and some of them are also intrafamilial affair such as socioeconomic status, family structure, and others; also extrafamilial affair such as peer influences, sexual health education (in which at some countries, are not applied), and lastly is community affair such as norms and values concerning adolescent pregnancy. Most of these factors are modifiable, but

some are not easily changed or cannot be changed at all.[7] Therefore our intention is to help Indonesian’s government through the modifiable factor which is knowledge by education in sexual health to decrease morbidities and mortalities of the future generation because of adolescent pregnancies by participating in Generasi Berencana (Planned Generation) Program by BKKBN (The Population and Family Planning National Body).

PROPOSED POLICY Our Proposed policy is that we would like to conduct a campaign about adolescent pregnancy through RAHIM or Remaja Anti Hamil Muda (Teens Against Teen Pregnancy). The constitution in Indonesia allows 16 years old as minimum age of marriage for women and 19 years old for men. We believe that this regulation is one of the contributing factor of adolescent pregnancy. Even more so, there are some cultural and religious beliefs and norms that indirectly support the idea of early marriage for women in some region in Indonesia. This is something that we can hardly prevent because it is within each and every individuals interest to believe so. However, Generasi Berencana (Planned Generation) Program by BKKBN (The Population and Family Planning National Body) has suggested that the ideal age for marriage is 21-25 years old, with health and psychosocial consideration.

Therefore, we would like to propose RAHIM as our campaign against adolescent pregnancy.

We would conduct this campaign once a month to spread information through videos, leaflets, advertisements, and lectures about the risks of adolescent pregnancy and why young girls should avoid it. In every lecture we would distribute pre-tests and post-tests to analyze the understanding of the young girls and efficacy of the program. The methods would explain the danger of adolescent pregnancy through real life cases to change the mindset of teens of early sexual intercourse and the consent of pregnancy that requires readiness of their physical being, emotion, and mentality.

Therefore, The RAHIM program would be organized for two target subjects of society. The first one would be the adolescents (age 15-19 years old) that pursue marriage registration at Kantor Urusan Agama (Religious Affair Office), where they would be given information through leaflets or videos about the consequences of adolescent pregnancy that it can bring many health risks for the mother and also about reproductive organ health. The second target is for adolescents who is in junior high schools and senior high schools where they would be given lectures along with videos, booklets, and quizzes about reproductive health and the danger of adolescent pregnancy and the contributing factor to adolescent pregnancy itself from health professionals or BKKBN (The Population and Family Planning National Body).

The RAHIM movement we believe will break the stigma in young girls that are afraid to talk about sexual matter because the society is not familiar to talk about it in public. Therefore, there is high possibilities that the young girls would be reluctant to try to understand about this issue and gets reliable information or to seek help because the nuance coming from the society is in a negative manner. The topic is still taboo in our society, even more so, that the current status quo in Indonesia is that there is very lack of sex education in peers, therefore people who are actually aware of the problem should be proactive to approach the young girls about the harm of adolescent pregnancy.

CONCLUSION Adolescent Pregnancy is one of the leading public health issue concerning maternal and neonatal health.

Mothers should be in their best capacity and readiness to be pregnant because pregnancy is not something you can take for granted, and it is not something that can go unplanned. For the sake of the neonatal health, the mother’s health should not be jeopardized. Especially in Indonesia, where some teenage girls in rural area do not even tell their families about their pregnancies, for the fear of cultural stigma, without realizing that the health risks that they’re facing is somewhat bigger than the stigma itself. Therefore, we would propose RAHIM as the movement that can help the government to raise awareness about adolescent pregnancies and its urgency, as well as helping teenage girls in planning their future life and their future child in their most ideal condition to be a mother to prevent the health risks when they are pregnant.

REFERENCES 1. Banerjee B, Pandey G, Dutt D, Sengupta B, Mondal M, Deb S. Teenage Pregnancy: A Socially Inflicted Health Hazard. Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine. 2009;34(3):227-231. doi:10.4103/0970-0218.55289.

2. World Health Organization 2014, Fact Sheet – Adolescent Pregnancy, viewed 28 October 2017, http://www.who.int/mediacentre/factsheets/fs364/en/ 3. Suan MA, Ismail AH, Ghazali H. A Review of Teenage Pregnancy Research in Malaysia. Kedah: Clinical Research Center. 2015.

4. Honig AS. Teen Pregnancy, International Journak of Adolescence and Youth, 2012;17:4, 181-18 5. Rahmadan H. Meningkatnya Usia Kehamilan Remaja. Jurnal Perempuan untuk Pencerahan dan Kesetaraan. Media Indonesia. 2013 6. Putri PH. Pengaruh Umur Kehamian Usia Remaja, Pengetahuan Ibu Tentang Anemia, dan Status Gizi Terhadap Kejadian Anemia di Kecamatan Sawahan Kota Surabaya. Medical Technology and Public Health Journal, 2017;01:01.

7. Langille DB. Teenage pregnancy: trends, contributing factors and the physician’s role. CMAJ : Canadian Medical Association Journal. 2007;176(11):1601-1602. doi:10.1503/cmaj.070352.

A Whole New Approach to Self-Administered Medical Abortion: Cooperation between Governmental and Non-Governmental Organizations (GO & NGO) towards Sexual and Reproductive Health Rights (SRHR)

White Paper & Video Pre-Conference Competition East Asian Medical Students' Conference (EAMSC) 2018 : Nepal AMSA-Indonesia

AMSA-Universitas Pelita Harapan 2017 Title of White Paper & Video White Paper : A Whole New Approach to Self-Administered Medical Abortion: Cooperation between Governmental and Non-Governmental Organizations (GO & NGO) towards Sexual and Reproductive Health Rights (SRHR)

Video : "If Only I Knew”

Name of University Universitas Pelita Harapan Authors 1. Steven Nanda 2. Calvin Oktavianus 3. Novia Lauren Sieto 4. Peter Sylvanus

Contact details of Regional Chairperson Elvira Lesmana rcindonesia@amsa-international.org +6285811240637

A Whole New Approach to Self-Administered Medical Abortion: Cooperation between Governmental and Non-Governmental Organizations (GO & NGO) towards Sexual and Reproductive Health Rights (SRHR)

Steven Nanda, Calvin Oktavianus, Novia Lauren Sieto, Peter Sylvanus Asian Medical Student Association – Universitas Pelita Harapan

With the Millenium Development Goals (MDGs) coming to transition to Sustainable Development Goals (SDGs) in September 2015, it remains to be in question whether the United Nation has successfully accomplished all of their goals. Among the eight interlinking MDGs are two goals concerning Maternal & Neonatal Health, which are goals number 4 in “Reducing Child Mortality” and 5 in “Improving Maternal Health”. Unfortunately, despite success in tackling global issues such as poverty or hunger, the problem of maternal & neonatal survival still prevails. The nation’s attempt of evaluation and reassessment of national goals do not change the fact that maternal and child mortality are still of great concern. Nations, particularly developing countries, have failed to completely address this issue.1 The issue of maternal & neonatal health has always been a huge global concern. A country’s health status is reflected by its maternal mortality rate. Estimations made by WHO, UNICEF, UNFPA, and the World Bank regarding maternal mortality in 2010 found several causes most identical to maternal death.2 On the major side, the causes of maternal mortality are associated with complications 1

Lawn, J. (2010). Are the millennium development goals on target?. BMJ, 341(sep14 2), pp.c5045-c5045.

2

World Health Organization, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990 to 2008.

related to physical health, such as haemorrhage, sepsis, eclampsia, or obstructed labor. However, out of the other causes of maternal death, unsafe abortion arises as a major problem that touches values beyond physical health, most notably moral, ethics, laws, and social stigma. Unfortunately, the reality presents an irony where the globe realizes the importance of maternal health, yet statistics of unsafe abortion have shown otherwise. In a global outlook, according to United Nations, unsafe abortion contributes to 4.7-13.2% of global maternal deaths each year. Between 2010-2014, it is estimated that 56 million abortions occurred worldwide each year, with the rate higher in developing countries. Approximately 25 out of 56 million abortions that happened worldwide between 2010-2014 are categorized as unsafe, with 8 million of them being the most dangerous. Unfortunately, this data is masked by the overall abortion rate that has declined, thus displaying a great incongruity. From 1995 to 2003, the overall number of abortions declined, but the unsafe abortion rate constitutes an increase from 44% to 48%.3 Unsafe abortion itself is defined as “practice done to terminate pregnancy by persons lacking necessary skills or in an environment that does not conform to minimal medical standards, or both.” 4 According to a research by Haddad, some people still adopt the traditional, less safe methods of abortion such as using sharp curettage, ingestion of toxic substance and foreign bodies, traditional potions, and many more inappropriate procedure. Furthermore, lack of awareness about abortion is also observed in women who use abortion pills but have no proper information about it. One of the reasons why women turn to unsafe abortion is due to the barriers that prevent them from aborting. The barriers include restrictive laws, high cost, stigma, and problems related to health-care providers themselves. This explains why women turn to clandestine procedures, as mentioned previously, to avoid being exposed by these barriers. Unfortunately, the barriers have not reduced unwanted pregnancies, but the opposite.

With unsafe abortion, woman are predisposed to complications that can threaten their life, including hemorrhage and incomplete abortion. Additionally, the problems of unsafe abortion is superimposed by the reality of woman’s reluctance to provide information regarding their unwanted pregnancy, which hampers the treatment of the complication.5 Women’s behavior towards abortion explains why clandestine procedures can seem very attractive. One focus that this paper would like to touch on is the method of self-administered medical

Estimates developed by WHO, UNICEF, UNFPA and The World Bank. http://www.who.int/reproductivehealth/publications/monitoring/9789241500265/en/index.html.

Published 2010.

3

World Health Organization. (2017). Preventing unsafe abortion. [online] Available at: http://www.who.int/mediacentre/factsheets/fs388/en/ [Accessed 31 Oct. 2017].

Ǻhman, E. and Shah, I. (2011). New estimates and trends regarding unsafe abortion mortality. International Journal of Gynecology & Obstetrics, 115(2), pp.121-126.

5 Warriner IK and Shah IH, eds., Preventing Unsafe Abortion and its Consequences: Priorities for Research and Action, New York: Guttmacher Institute, 2006.

4

abortion. Medical abortion is defined as a non-surgical abortion using medication, such as an oral abortion pill. Abortion pills have made access to abortion easier, where the availability has increased worldwide. The significance of this availability is that there is greater access to safe and unsafe abortions. One type of medication, Misoprostol, is easily accessible and stored, inexpensive, and simple to administer. These factors make Misoprostol particularly appealing to women seeking covert abortions. When provided under supervised medical care, medical abortion has a success rate of approximately 95 per cent.6 On the contrary, medical abortion in areas where medical supervision is rare becomes a huge uncertainty. In areas where women depend on social network instead of healthcare service for dosage information and medical follow-up, the efficacy of medical abortion pills becomes in question. To what extent does the unsupervised self-administration of medical abortion provoke complications and have a lower success rate? The consensus is that medical abortion is most likely safer than other means of self-induced abortion using physical objects or caustic substances. However, women who take incorrect dosages may risk potentially serious complications such as prolonged bleeding if they do not receive prompt medical attention. This means that standardized information and instructions regarding medical abortion is critical. Therefore, with the great potency of selfadministered medical abortion, we believe that this method can be the key to improving abortion rates if done properly. This method is so appealing to women because the experience is easy and harmless, and the idea of aborting means that their financial burden of having another child is disregarded and they can continue working to support their families.7 Indonesia’s view on abortion may be reflected by their regulations. Indonesia, like many developing countries today, have restrictive abortion laws, with PP No.61 2014 about Reproductive Health, stating that abortion can only be done based on a medical emergency or pregnancy due to rape.8 On the contrary, rates of unsafe abortions in this country are striking. Over three fourths of the abortions in South Asia and nearly two thirds of the abortions in South-East Asia are highly restricted and most of these are unsafe. Morbidity and mortality from medically unsafe abortions remain unacceptably high in South and South-East Asia.9 In addition, the high rates of unsafe abortion in South-East Asian countries may be attributable to their view on abortion. Countries in this region that adopt a strong patriarchal culture often view pregnancy – not the abortion – that is “illegal”, where a legal pregnancy being one that occurs within marriage to a woman who is not considered too old to be sexually active.

6

Warriner IK and Shah IH, eds., Preventing Unsafe Abortion and its Consequences: Priorities for Research and Action, New York: Guttmacher Institute, 2006.

7 Tousaw, E., Moo, S., Arnott, G. and Foster, A. (2017). “It is just like having a period with back pain”: exploring women’s experiences with community-based distribution of misoprostol for early abortion on the Thailand–Burma border. Contraception.

8

PERATURAN PEMERINTAH REPUBLIK INDONESIA NOMOR 61 TAHUN 2014. (2017).

9

Warriner IK and Shah IH, eds., Preventing Unsafe Abortion and its Consequences: Priorities for Research and Action, New York: Guttmacher Institute, 2006.

Premarital sexual activity is not considered normative, and many families still adopt this tradition. The significance of this culture is that unmarried adolescents find themselves in socially vulnerable situations. Under this situation, these women are under greatest pressure. The risks for these women are greater due to the social unacceptability, where the conditions and situation force them to end their pregnancy. On the contrary, the idea that pregnancy is socially unacceptable is also chained to the difficulty of women accessing abortion. The problems of social stigma and the need for confidentiality and protecting the honor of the family is the primary concern and outweighs any other risks.10 This seems to be the case in Indonesia, a country which is family and community oriented. As a result, medical safety often has to take second place to concerns of keeping harmony in the family.

In this paper, we realize that women have their own Sexual and Reproductive Health Rights (SRHR). Unfortunately, under the wrong mediation, these rights can be abused or used improperly, predisposing to unsafe abortion. Therefore, we propose an intervention from the government, particularly the Ministry of Communication and Informatics together with the Ministry of Health, to protect women’s rights. The media, in particular the Internet and online world, is a powerful weapon that can be beneficial when used properly, but can otherwise backfire. Both ministries have great power and force on determining the course of Indonesia’s maternal health in the future, where we believe that both ministries can significantly ameliorate the maternal mortality rate in Indonesia. Through this paper we would like to elaborate on how this cooperation can be reinforced and implemented. The intervention we propose is having the Ministry of Communication and Informatics to remove and prevent abortion pills that are sold illegally online (See Appendix). This intervention can be cooperated with the Ministry of Health in ensuring that distribution of abortion pills in the future is done in a standardized and licensed method, limited to healthcare centers and stakeholders having a clear trading license. Hence, through this cooperation, we can improve the quality of women’s right to sexual and reproductive health. Our team has seen the urgency to intervene on self-administered medical abortion done online, because the Internet has so much potential, where it can easily be an online market that allows easy publication and trading of items. The Internet can be a blessing but can also be a disaster, depending on how it is implemented in the country. For women seeking abortion, the internet serves as an answer to abortion that is easily accessible and free of judgment. In addition, we also realize how Internet can easily reach all users from different age and population. A particular audience that we are targeting from this policy is adolescence. Mortality is frequently highest among adolescents since they are slow to recognize the pregnancy, are least able to afford appropriate care, and are most vulnerable to receiving poor quality care and using ineffective methods.11 We believe that women in the

10

Glasier A, Gülmezoglu AM, Schmid GP, Moreno CG, Van Look PF. Sexual and reproductive health: a matter of life and death. The Lancet. 2006 Nov 10;368(9547):1595-607.

11

Warriner IK and Shah IH, eds., Preventing Unsafe Abortion and its Consequences: Priorities for Research and Action, New York: Guttmacher Institute, 2006.

adolescence can be significantly empowered by the policy we are proposing. Hence, through this cooperation, we can improve the quality and safety of women’s sexual and reproductive health rights.

It should be noted that this policy does not stand by itself. The implementation of the policy to block illegal abortion pills sold online will not be effective if the restriction is not balanced by an active approach. This leads to another policy that we would like to propose, which is called peer counseling program. Peer counseling is a method of providing knowledge, emotional, social or practical help for people in need, or clients, by finding solutions to their problems. This help is provided by trained peer support workers, known as peer counsellors. While the counsellors should be professionals like psychologists, law-enforcement personnel, and emergency medical responders; principally, a peer counselor can be any stakeholder.12This program can be accomplished by colleagues, self-help organizations, and most importantly, medical students.

As medical students, we can be peer counsellors towards sexual reproductive health and rights (SRHR) by acting as active listeners and understanding the client’s perspective. As counsellors, we are required to have the ability to accept, listen, and assist. This includes mentoring, reflective listening, and counseling sessions that allow us to explore more about clients' issues in a way that does not make them uncomfortable. One of the key aspect of peer counseling is neutrality; to be objective and let clients decide their own solution.13 This is very important since being in the equal position as the client means that women’s SRHR is greatly empowered, and client can gain confidence and self esteem in their decision making.

Beyond medical students, the effort to reduce unsafe abortion should be present in activists and NGOs. Their attempt to defend woman’s rights whilst complying to the country’s abortion law should be supported and embraced by the government. The cooperation between GO and NGOs here can be significant towards improving maternal health. One well-known NGO working in sexual and reproductive health rights is Samsara, a rights-based organization that promotes access to SRHR and safe abortion.14 This organization serves as an online peer counsellor that provides hotline and source of legit and credible information for women considering abortion. This form of peer counselling, we believe, is an innovative approach. This method can be an effective way of reducing unsafe abortion,

12

Nugent, P. (2017). What is PEER COUNSELING? definition of PEER COUNSELING (Psychology Dictionary). [online] Psychology Dictionary. Available at: https://psychologydictionary.org/peercounseling/ [Accessed 31 Oct. 2017]

13

Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential. The lancet. 2007 Apr 13;369(9568):1220-31

14

The Asia Safe Abortion Partnership Annual Report 2014. (2017). .

where women, particularly teenagers, can actually turn to the Internet for reliable information regarding family planning instead of being misguided to illegal websites selling abortion pills.

In reality, the impacts posed by unsafe abortion can be reduced. WHO has called unsafe abortion as one of the easiest preventable causes of maternal mortality and a staggering public health issue at the same time.15 There are many factors that can prevent unsafe abortion, including sex education, effective contraception, and proper care of complication. The intervention to unsafe abortion should consist of multidisciplinary parties, where efforts taken by all sides can give a synergic effect in improving maternal health. Besides the government, the roles of research, grassroots organizations, health providers, activists, and media are vital in highlighting the importance of family planning. The emotional, physiologic, and financial cost on women and families, as well as the burden on the economic health system, should no longer be ignored. On the contrary, this has not been applicable in many countries and the problem has never been resolved. Political, social, and religious obstacles can hinder maternal health.

The policy we are proposing can be recognized as an active approach to terminate unsafe abortion in the midst of restrictive abortion law. This includes the cooperation between Ministry of Communication and Informatics and Ministry of Health in blocking illegal online trading of abortion pills and ensuring that abortion pills traded online meet the standard set by the government. Common taboos like pornography are already being suspended, therefore we believe that illegal online trading and sites related to abortion pills should also be blocked. In addition to restriction, the active approach that we propose involves the idea of peer counselling, where basically any NGOs, from rights-based organization to us as medical students, can act as counsellors for women seeking abortion. Samsara, a well-known NGO, is a good example of an organization that utilizes the Internet as a method for peercounselling, which is through their online hotline and assistance. The principle of peer counseling is neutrality, where counsellors are on the same level as the clients, and ultimately it is the client’s decision and rights that are empowered. Of course, the peer-counselling that we are proposing should comply to the government’s laws, meaning that the government continually supervise these NGOs to be in line with the government’s aspiration and that they do not succumb to personal gain and agenda. The government should also support the movement made by these stakeholders, as a collective effort to reduce unsafe abortion.

In short, until unsafe abortion is eliminated, women and public health systems will continue to suffer the consequences of abortions performed under unsafe conditions. Although liberalizing abortion

15

Haddad, Lisa B. , MD, MA. Nour, Nawal M., MD, MPH. (2017). [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2709326/ [Accessed 31 Oct. 2017].

laws is shown to reduce rate of unsafe abortion,16 we must not forget that Indonesia is a country with strong values. Embracing the country’s value and legislation and improving maternal health at the same time can only be achieved by a proper intervention from the government. The policy that we provide integrates the use of online media and self-administered medical abortion, where cooperation between GO and NGOs can collectively reduce unsafe abortion rates. This cooperation can ultimately serve as an antidote to the country’s striking unsafe abortion rates. Preventing unsafe abortion is imperative if Indonesia is to achieve the MDGs and now SDGs. It is of paramount importance that women use their sexual and reproductive rights in a healthy way.

Works Cited Ǻhman, E. and Shah, I. (2011). New estimates and trends regarding unsafe abortion mortality. International Journal of Gynecology & Obstetrics, 115(2), pp.121-126.

Asap-asia.org. (2017). Country Profile – Indonesia – ASAP-ASIA. [online] Available at: http://asapasia.org/country-profile-indonesia/ [Accessed 31 Oct. 2017].

Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential. The lancet. 2007 Apr 13;369(9568):1220-31 Glasier A, Gülmezoglu AM, Schmid GP, Moreno CG, Van Look PF. Sexual and reproductive health: a matter of life and death. The Lancet. 2006 Nov 10;368(9547):1595-607.

Haddad, Lisa B. , MD, MA. Nour, Nawal M., MD, MPH. (2017). [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2709326/ [Accessed 31 Oct. 2017].

Lawn, J. (2010). Are the millennium development goals on target?. BMJ, 341(sep14 2), pp.c5045c5045.

Nugent, P. (2017). What is PEER COUNSELING? definition of PEER COUNSELING (Psychology Dictionary). [online] Psychology Dictionary. Available at: https://psychologydictionary.org/peer-counseling/ [Accessed 31 Oct. 2017] PERATURAN PEMERINTAH REPUBLIK INDONESIA NOMOR 61 TAHUN 2014. (2017).

16

Haddad, Lisa B. , MD, MA. Nour, Nawal M., MD, MPH. (2017). [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2709326/ [Accessed 31 Oct. 2017].

The Asia Safe Abortion Partnership Annual Report 2014. (2017).

Tousaw, E., Moo, S., Arnott, G. and Foster, A. (2017). “It is just like having a period with back pain”: exploring women’s experiences with community-based distribution of misoprostol for early abortion on the Thailand–Burma border. Contraception.

Warriner IK and Shah IH, eds., Preventing Unsafe Abortion and its Consequences: Priorities for Research and Action, New York: Guttmacher Institute, 2006.

World Health Organization. (2017). Preventing unsafe abortion. [online] Available at: http://www.who.int/mediacentre/factsheets/fs388/en/ [Accessed 31 Oct. 2017].

World Health Organization, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990 to 2008. Estimates developed by WHO, UNICEF, UNFPA and The World Bank. http://www.who.int/reproductivehealth/publications/monitoring/9789241500265/en/index.html .

Published 2010.

Appendix

Image 1: Easy Instant Abortion (in Indonesian: Aborsi murah cepat) written in Google Search Engine

Image 2: A website that freely trades abortion pills online