Indonesia faces the development question of how to ensure that obstetric interventions, such as caesarean section, are appropriately available and not overused.

Most Australians don’t realise it, but Indonesia is a wealthier country than Australia. Examining gross domestic product (GDP) by purchasing power parity (PPP), what money actually buys in each country, shows that Indonesia ranks as number 16 in the world, with an annual GDP (PPP) of over US$1.2 trillion. By contrast, Australia ranks as number 19, with a GDP (PPP) of just under US$1 trillion. At the official exchange rates, however, Australia is richer (US$1.5 trillion compared to Indonesia’s just under US$800 billion)¹, but PPP is a more realistic comparison of wealth because it reflects what money can actually buy in that country (goods, services and labour are usually significantly less expensive in Indonesia than Australia). However, even the difference in GDP by official exchange rates will soon disappear between the two countries, as Indonesia’s faster growth rate than Australia (six per cent compared to three per cent) will increase Indonesia’s wealth disproportionately to that of Australia.

Why should Australia give aid to Indonesia?

Indonesia is still a developing country. When the pie of national wealth is cut up among each population, Australia’s 23 million inhabitants receive unimaginably bigger slices of wealth than do Indonesia’s 250 million inhabitants. A developing country such as Indonesia has different priorities in expenditure², spending more on infrastructure and poverty eradication. Australia’s healthcare spending is just under nine per cent of GDP compared to Indonesia’s three per cent. With ten-times the population and one-third the proportional healthcare expenditure, Indonesia spends less than 1/30th on the healthcare of each of its citizens than Australia does. Tellingly, the maternal mortality rate in Indonesia (220:100 000) is 30-times Australia’s maternal mortality rate (7:100 000).

How is caesarean section important?

About 30 million of the 200 million women who become pregnant every year will develop life-threatening complications requiring emergency treatment.² Caesarean section (CS) is the most significant of these medical interventions and the most commonly performed major obstetric intervention.³ While it can be lifesaving, it has the most significant physical impact with the greatest potential for short, medium- and long-term complications for the mother and baby. Most importantly to a developing country such as Indonesia, where resources are relatively scarce, it is the commonest major obstetric procedure with the highest cost to the health system.

The 2007 Indonesian Demographic and Health Survey (IDHS) data⁴ indicate that the goal of making such emergency obstetric intervention available to all pregnant women is slowly being achieved and this has been associated with remarkable improvements in health outcomes. Births with trained medical or midwifery assistance have increased from 46 per cent in 1995 to 77 per cent in 2009, accompanied by significant reductions in neonatal and maternal mortality.⁵ In the 2007 survey, 93 per cent of women had at least one antenatal visit from a health professional, (79 per cent of this care by a midwife), and 74 per cent were delivered by a health professional, although the majority of Indonesian women still have their baby at home, (54 per cent total, 30 per cent urban, 71 per cent rural). This medicalisation of childbirth has been facilitated by initiatives such as the health insurance scheme for the poor, introduced in 2005, financed by a reduction in the fuel subsidy.⁵

What is the Indonesian CS rate?

IDHS data suggest that the Indonesian CS rate in 2007 was 7.3 per cent. This figure was derived from 1020 CSs reported out of 14 043 births covered by the survey. Since there were more than five million births in Indonesia in 2007, even though the sampling of the survey is as best as can be designed, the validity of such a large extrapolation has been questioned.

This is particularly so in the light of reported referral hospital CS rates of 30–50 per cent.6 This high figure may reflect successful triage and referral, or it may be that CS is being performed for non-standard indications. Although these rates may at first appear to be excessive, they may also be appropriate in a country where the majority of births (54 per cent) occur at home. If only very ill women are being referred to the hospitals to have CSs⁷, then this may actually be appropriate practice. However, according to IDHS data, CS is more common in urban women (11.3 per cent versus 3.9 per cent in rural women). It is also commoner in the highest wealth quintile (16.8 per cent versus 1.8 per cent in the poorest). These statistics suggest CS practice is being done inappropriately, in that it may be too high in one group or, conversely, too low in another. By linking indications for CS with clinical outcomes for both mothers and babies, as possible in our study, the appropriateness of CS practice can be evaluated.

Is this CS rate appropriate?

The often quoted WHO 15 per cent ‘ideal CS rate’⁸ is based on poor evidence (level V, from expert opinion). The optimum CS rate is very controversial. In low-income countries where rates of CS are typically low, the caesarean rate can be negatively correlated with neonatal and maternal mortality.⁹ There is some evidence to suggest rates less than ten per cent are suboptimal, and an increase in CSs from that rate would prevent both maternal and perinatal deaths.¹⁰ However, although increased access to CS may improve maternal and neonatal outcomes, CS rates of over 15–20 per cent may not result in better outcomes.^11,12 Little association has been found between CS rate and mortality outcomes in high-income countries.9 Moreover, CSs require many resources and can divert such resources from more basic and cost-effective healthcare.

What progress has Indonesia made?

Indonesia has made significant advances in education and health. Improvement in adult literacy has increased from 61 per cent in 1971 to 93 per cent in 2003, especially among women. Infant mortality has fallen from 142 per 1000 live births in 1971 to 34 per 1000 in 2007. Per capita income has improved significantly. Despite this, there remain considerable obstacles to improving health efficiency, especially with regards to obstetric intervention. Whereas developed nations typically have national databases in order to monitor perinatal outcomes and the benefits or harm caused by interventions, such systematic routine data collection does not currently exist in Indonesia.¹¹ Monitoring outcomes of interventions, such as CS, and linking them to outcomes is not possible.

The most quoted maternity statistics are from the IDHS conducted every four to five years and last completed in 2007.⁴ It is a cluster survey, stratified for urban and rural, using random sampling. Sampling approximately 35 000 households, results are extrapolated to over 205 million people. The validity of this survey can be questioned, not only from the exponential extrapolation of its data, but its reliance on unreliable memory recall¹¹ from participants in an unwieldy 736-question-field questionnaire.

What can we do?

We are developing a study to facilitate perinatal epidemiologic data collection in three tertiary maternity hospitals in Indonesia (Denpasar, Malang and Surabaya), each with CS rates of about 40 per cent and will aim to use an audit cycle in each centre, to establish consensus guidelines. The three Indonesian hospitals are all centres of excellence where opinion leaders practice and teach. A network of these sites, linked to an Australian clinical and academic team, has been formed over the past four years, with annual clinical and scientific meetings aimed at improving the practice of high-risk obstetrics and promoting formal maternal fetal medicine training. At the most recent Australian/Indonesian combined clinical meeting in Denpasar, participating clinicians identified CS audit and perinatal epidemiology practice as an area where we could learn from each other and where research was most needed. Transferring skills in perinatal epidemiology to the Indonesian medical team and expanding the role of Indonesian midwives into epidemiologic research will encourage sustainability.

CS is costly, diverting resources and personnel that could be used more effectively elsewhere. Indonesia has policies to improve pregnancy care by increasing hospital births and replacing traditional birth attendants with professionally trained midwives and obstetricians. CS, the most significant obstetric intervention, reduces maternal and perinatal morbidity and mortality when it is available to pregnant women. As we have discovered in Australia, however, if CS is widely available, it may be used inappropriately. Helping Indonesia to learn from the Australian experience may avoid such mistakes being unnecessarily repeated.