Pre-term births in Indonesia contribute to high infant moratality.

Giving babies a fighting chance from the start. PHOTO: Natalie BaileyLinda Rullis sold her motorcycle and borrowed money from relatives to cover neo-natal treatment for her daughter, who was born after only 24 weeks of pregnancy, barely weeks within the threshold of survival. The baby girl is now one year old and weighs 5.1kg.

“I insisted on taking her home after she had been treated for four months because I couldn’t afford the treatment anymore,” Rullis, 30, told IRIN. “When she was born she weighed only 690g, but luckily she seems to be doing just fine now.”

The World Health Organization (WHO) defines any birth before 37 weeks (259 days) of pregnancy as pre-term, while a full-term pregnancy is anywhere from 37 to 41 weeks.

A recent multi-agency report ranked Indonesia among 10 countries worldwide with the highest number of pre-term births, where 15.5 babies out of every 100 live births are born too early - about 676,000 babies annually.

Globally some 15 million infants - more than one in 10 births - are born too early each year, and more than one million die shortly after birth. Countless others suffer some type of lifelong physical, neurological, or educational disability, according to the report.

Indonesia’s rank in the ninth position puts it above Pakistan and below Mauritania. Belarus, Ecuador, Latvia and Finland have among the lowest rates of too-early births among countries that provided the UN data.

"The dominant cause of pre-term births in Indonesia is infections, including vaginal and renal infections,” said Ali Sungkar, an obstetrician-gynaecologist and lecturer at the medical school of the University of Indonesia in Jakarta, the capital.

“Most of those mothers who give birth to pre-term babies come from low socio-economic backgrounds. They have low body mass index and suffer from anaemia,” he said.

Smoking, alcohol consumption and depression also contribute to pre-term births, and once a woman delivers an infant prematurely, she is more likely to do so again Sungkar said.

He estimated that such births cost the state 10 times more per child than full-term deliveries, and “the government won’t have the money to cover all the costs,” but added that there was little research available on this.

Indonesia has no universal health insurance, but poor people can get free medical treatment if they present the necessary documents. Patients usually cover around 73 percent of their health costs out of their own pockets, according to government data reported to WHO in 2009.

20 million vulnerable

More than 76 million of Indonesia’s 240 million people are covered by Jamkesmas, a health-fee waiver for the poor, but a legislator recently told local media that an estimated 20 million poor people are not covered because their data cannot be verified.

The government has said it will increase the number of people eligible for Jamkesmas to 86.4 million in 2013, in line with updated data collected by the Central Bureau of Statistics. An amount of 7.4 trillion rupiah (US$791 million) has been allocated to health subsidies for 2012, with each qualified family entitled to up to 2.5 million rupiah ($266).

Sungkar said antenatal care played a key role in preventing pre-term births and more training should be given to midwives and clinic personnel. The Indonesia Health Profile 2010 noted that four out of 10 pregnant women do not make the recommended four antenatal visits.

Ivan Sini, an obstetrician-gynaecologist who practices in a private hospital in Jakarta, said a lack of financial resources and poor healthcare infrastructure were among the obstacles to curbing pre-term births.

“Puskesmas [government-run community health clinics] and referral health systems are not evenly available throughout the country,” Sini pointed out. “Even with limited budgets, the government should be able to expand the reach of these peripheral services.”

In 2007 the country had less than 23 health workers per 10,000 residents, the minimum number needed to provide life-saving care, according to WHO.

A Health Ministry expert in health financing, Triono Soendoro, recently told state media that Indonesia’s health system was facing challenges in reforming health management, improving infrastructure, and reaching people living in the more remote parts of the far-flung archipelago.

This story was first published in IRIN.