Advances in Social Science, Education and Humanities Research, volume 499 2nd International Conference on Law, Governance and Social Justice (ICOLGAS 2020)

The Role Of Law In The Improvement Of Maternal Health In Central

Dyah Hapsari Prananingrum1 1Satya Wacana Christian University, Salatiga – E-mail: [email protected]

Abstract- This research focuses on the issue of how law Motherhood Initiative. This was followed later by should be developed to improve maternal health issues Gerakan Sayang Ibu or Love Mom Movement at the regional level, particularly in Central Sumba , , Indonesia. Based on the program initiated in 1996 by the President of the presumption that law can be used as a tool to achieve Republic of Indonesia. This program was massive the goals of the community, this study aims to assess the in that its implementation required a wide scope of current policy and regulations concerning maternal health and to prescribe the development of law needed involvement of the health sector as well as the to address this crucial issue. This research adopts other related sectors. empirical approach in which valid data were collected One of the primary programs which has been directly from field assessment. Interview with key informants (including local government officials and devised to overcome maternal mortality issue was traditional leaders) and documentary study are the large-scale deployment of midwives to villages main methods used in collecting data. Techniques to which aims to bring access to mother health service confirm data validity were intensely applied, mostly triangulation (in terms of both source and method) and closer to the community. Another attempt that has source-based cross-checking. This research adopts been carried out is the implementation of Making qualitative analysis which is conducted simultaneously Pregnancy Safer strategy, which was formally along with data collection process. This research found that local regulation needs to be issued to regulate launched in 2000. In 2012, the Health Ministry various aspects needed to improve maternal health launched Expanding Maternal and Neonatal standard in Central Sumba. Survival (EMAS) program for the purpose of

Keywords- Function Of Law; Indonesia; Maternal reducing maternal and neonatal mortality rate by Health; Sumba. 25%. The risk of maternal death due to childbirth in I. INTRODUCTION Indonesia is 1 of 65 childbirths which is far higher In Indonesia, since the year of 1990 strategic than 1 of 1,100 childbirths in Thailand. In addition measures have been taken to reduce Maternal to this, disparity of inter-regional (provincial) Mortality Rate (MMR) through Safe Motherhood maternal mortality in Indonesia is still high. To approach, based on the sound assumption that speed up the decrease in MMR a Continuum of every pregnancy carries risks, despite the mother's Care approach may be used in this regard as a way good health condition before and during pregnancy. to tackle the deaths of mothers, babies, and Through this approach, the World Health children. This concept is one of the undertakings in Organization (WHO) developed "Four Pillars of maternal and infant health issue by the Ministry of Safe Motherhood" to describe the different Health. The Continuum of Care Approach, measures to be taken to save mother and her baby particularly in maternal and infant health service, in one single integrated process. The four pillars focuses its attention on health services provided are family planning, antenatal care, clean and safe during the first 1000 days of life. This is in line delivery, and essential obstetric care. These four with the work plan to accelerate the attainment of pillars serve as one Millennium Development Goals (MDGs), where

target of health development program is set based of the methods to support maternal and infant on the pertaining life cycle condition. Hence, it's health. targeting pregnant women, women in labour, As part of its effort to reduce MMR in women in postpartum period, and breast-feeding Indonesia, the government through its Health women; and covering as well certain age groups, Ministry since 1990 has launched the Safe such as babies, under-five-year-old children,

Copyright © 2020 The Authors. Published by Atlantis Press SARL. This is an open access article distributed under the CC BY-NC 4.0 license -http://creativecommons.org/licenses/by-nc/4.0/. 466 Advances in Social Science, Education and Humanities Research, volume 499

elementary school aged children, and women of regency of Central Sumba. It is expected that the child-bearing age. results of this study could also be implemented in Efforts that have been put in Continuum of Care other regions (municipals or regencies) to address for mothers among others is ensuring that every similar problems. mother can have proper access to qualified health service, such as health service for pregnant women, II. PROBLEMS childbirth care by skilled health personnel in health Based on the previous description, the research care facilities, postpartum care for mothers and issues that will be addressed in this paper are babies, special care and referral when complication specified as follows first, how health care practices occurs, facilitation to obtain pregnancy and were implemented to respond maternal health maternity leave, and family planning service issues in Central Sumba? And second, how could law be utilized to improve maternal health in Figure 1. Thought Flow of Health Development Plan Central Sumba? and National Health System [1]

III. RESEARCH METHOD This research adopts empirical approach in which valid data were collected directly from field assessment. Interview with key informants (including logal government officials and traditional leaders) and documentary study are the main methods used in collecting data. It is acknowledged that in such research the validity of data is crucial, so techniques to confirm data validity were intensely applied, mostly To ensure that the goals of health development triangulation (in terms of both source and method) are attained, the National Health System (Sistem and source-based cross-checking. This research Kesehatan Nasional or SKN) was arranged based adopts qualitative analysis which is conducted on Presidential Regulation No. 72 of 2012 on simultaneously with data collection process. National Health System. SKN is a health To approach the second research issue, management system administered by every documentary study on relevant regulations which component in Indonesia, which basically requires are related to the protection and improvement of integrative approach and mutual support from all of maternal health was also performed properly. In the stakeholders to ensure the achievement of the this regards, the regulations studied includes law highest level of health in the community. and regulations at the national level as well as at In reality, the health level of women, including the regional level. maternal health aspects is, in particular, affected predominantly by various factors which most of IV. DISCUSSION them are beyond the scope of health sector control. 1. Implementation of Health Care Practices for Thus, promoting health efforts which exclusively the Improvement of Maternal Health in Central involves only the health sector will less likely be Sumba able to create required health preconditions. The high MMR in East Nusa Tenggara This situation subsequently raises some issues Province was reckoned with data from Cities and such as the implementation of maternal health Regencies; one of them is from the Regency of standards and procedures in a particular social Central Sumba. The number of mortality cases environment where cultural factors play a reported in Central Sumba fluctuates year after substantial role, such as in Central Sumba. From year. In 2012, there were 2 maternal mortality the legal point of view, the relevant issue emerging cases; while in 2013, there was 1 maternal from this situation, which is at the center of this mortality case. Maternal Mortality were 2 cases in study, is how law should be developed to address 2016. To suppress maternal deaths during the problem of maternal and child health in the childbirth, as mentioned above, the following major

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attempts are made: increasing the pregnancy class outpatient and outreach services (reproductive coverage and the improvement of antenatal service. health, pregnancy care, after childbirth and child Figure 2. Mother and Child Health Care Continuum health services), and one through integrated family Concept and community care throughout the life cycle. Mothers and babies have a high risk in the first days after birth, and the lack of a defined care package after childbirth is an important gap, which also contributes to discontinuity between maternal The concept of a "continuum of care" has and child health programs. emerged as a new paradigm for dealing with Likewise, because family and community maternal, infant and child mortality and is very packages tend not to be considered part of the important for combating maternal, infant and child health system, some countries have made mortality. The first dimension of this continuum is systematic efforts to scale it or integrate it with time - from before pregnancy, through pregnancy, other levels of care. Building a continuum of care childbirth, and the days and years of life. The for maternal, infant and child health with this second dimension of this continuum is place - it package will need to test effectiveness in various connects various levels of home, community and settings; policy support for integration; investments health facilities. to strengthen the health system, and operational results-based management, especially at the district level. Figure 3. Dimensions of place of care continuum Pregnancy Class Coverage is operationally defined as the percentage of Puskesmas (Community Health Centres) organizing pregnancy class at a minimum of 4 times a year in their working area. Based on data collection from 5 sub- districts in Central Sumba Regency from 2012 to 2013, it shows that the coverage percentage of pregnancy class has not yet entirely been reported Special interventions, delivered at certain time by all Puskesmas, thus there's no data that can be frames, have multiple benefits. Linking generated from Central Sumba Regency's Health interventions in packages can reduce costs by Profile in 2012 and 2013. Pregnancy class is enabling greater efficiency. The continuum for the regarded as highly key as a medium to promote health of mother, baby and child usually refers to maternal and infant health. In pregnancy class, the continuity of individual care. Continuity of care participants will receive various information about needed throughout the life cycle (adolescence, healthy pregnancy, childbirth, exclusive pregnancy, childbirth, postnatal period, and breastfeeding, baby care, nutrition intake for childhood) and also between places of care children, and many more. (including household and community, outpatient Basic health service that has been carried out by and outreach services, and clinical care health service facility, one of them is the Antenatal arrangements) . Service (V1 and V4). V1 coverage or access to We define a population-level or public service for pregnant mothers making their first visit health framework based on the delivery of to health service facility to obtain the antenatal integrated services throughout the life cycle, and service. Whereas V4 is a comprehensive account of propose eight packages to promote maternal, infant pregnant mothers who have received pregnancy and child health. These packages can be used to service that follows pregnancy service standard and provide more than 190 separate interventions, also have made at least four visits distributed in one which will be difficult to improve one by one. The time visit during the first trimester, one visit in the packages include three delivered through clinical second trimester, and twice during the third care (reproductive health, midwifery, and care for trimester. sick newborns and children); four through

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National target V-1 coverage is 100%, V-4 is Regency's APBD (Anggaran Pendapatan dan 95%, and complication management is 75%. In Belanja Negara or Regional Budget) (74.94% in Central Sumba Regency, in 2012 and 2013 V-1 2012 and 75.39% in 2013) and APBN (Anggaran coverage is 100%. However, in 2015 V-1 coverage Pendapatan dan Belanja Nasional or National was down to 72.3%. Whereas, V-4 coverage in Budget) for an amount of 25.06% in 2012 and 2012 was 76%, and experienced a slight increase 24.61% in 2013. Looking at the total budget of by 78.2% in 2013. V-4 coverage declined once Regency's APBD, the Central Sumba Regency's more in 2015 for as much as 69.5%. The APBD allocation for health in 2012 was 5.45% and percentages of V-1 ad V-4 coverage in Central was raised to 6.61% in 2013. Total health budget Sumba Regency are still far below the National per capita in 2012 was Rp443,101.- per capita/year; Target. On the other hand, after the percentage of while in 2013 was Rp 495,007.54 per capita/year. maternal case for complication management in Indicators of Maternal Health which are still 2012 was only 35.4%, it then had a steep increase below the national target in Central Sumba by 84.7% in 2013. Regency suggest a complex issue. Some indicators The Central Sumba Regency has 8 Puskesmas demonstrate a decline in the past few years. operating in its area, which are located in Wairasa, Apparently having near-ideal ratio of health Mananga, Maradesa, Lendiwacu, Malinjak, personnel is not enough to resolve complex issues Lawonda, Pahar, and Weeluri. Since the size of in Maternal Health field, moreover with general these areas varies, the number of the Puskesmas practitioners ratio dominated by non-permanent doesn't correspond to the number of sub-districts. staff which only add to the already existing Some sub-district doesn't have Puskesmas problem where doctors are frequently being (Katikutana) in their area; while in other areas, they transferred due to their short term of office. Even have more than one Puskesmas (such as Umbu with every Puskesmas carries out supporting Ratu Nggay which has 3 Puskesmas). program for Maternal Health once a month, this The numbers of facilities in Central Sumba remains insufficient to improve maternal health Regency are 29 POLINDES (delivery service comprehensively. clinics), 1 health clinic, 186 Posyandu (centres for To improve maternal health, it demands an pre- and post-natal health care), 8 Puskesmas, and 1 inter-sectoral collaboration where hard work hospital. It is that, however, Puskesmas that exclusively on the side of the health sector would provide PONED (Neonatal Obstetric and Basic not be sufficient, since help from other sectors Emergency Service) which currently are short in would be equally needed. Community human resources. empowerment needs to be done by intensifying the Health personnel provided is sufficient in involvement of village officials and inspiring more number, with a percentage around 70% moving on active involvement of the local community. Instead to an ideal ratio, with the following details: 15 of passively waiting for programs that Puskesmas medical personnel, 171 nursing personnel, 73 launches, they are also active in social activities, midwifery personnel, 8 pharmacy personnel, and such as in Posyandu, become the helping hand of 31 other health personnel. The numbers of doctors Puskesmas, and active nutrition cadres. For this in Central Sumba Regency are 2 medical reason, a precise budget allocation that will specialists, 12 general practitioners, and 1 dentist. appropriately meet the needs is required to avoid The competency of health personnel has also been the community from having double burden. adequate and kept on being improved. For 2. The Role of Law in the Improvement of midwives, the minimum qualification for education Maternal Health in Central Sumba they need to have is D3 level (a 3 Year Study The discussion of the second issue relates to the Program); as for nurses, they are required to have concept of the development of law. As a concept, professional qualification of ners. development of law could be understood in at least The Health Office of Central Sumba Regency two meanings. Firstly, development of law as a set received a budget of Rp28,235,319,741.- in 2012 of measures to modernize law. In he context of this and Rp32,475,464,892.- in 2013. This budget is paper, it means the renewal of the positive law to composed of mainly from Central Sumba fit the need to serve the community, especially the

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mothers whose interests need legal protection. Budget allocation itself would not only concentrate Secondly, development of law could also be on curative program, but also on preventive and understand as the measures to functionalize the law promotive programs to improve maternal health. in the course of development. Unlike the At this point, local laws and regulations could modernization of the law, this second meaning of be used to facilitate the involvement of the the development of law requires the existing laws community members as well as other stakeholders to be used as a way to encourage social changes as in dealing with maternal health issues. Local required by a developing society. regulations on the improvement of maternal health "Ubi societas ibi ius" (wherever there is could be issued, in which particular regulaion on society, there is law) is an adagium commonly the participation of the community and quoted to assert the fact that law and society are stakeholders in maternal health issues could be two inseparable elements. Further, it is only inserted. In addition, the regulations could also be sensible that every society embraces a notion that arranged to mobilize the provision of funds needed the law operates amongst them is not just an to improve maternal health standard in Central ordinary law, but a good law. A good law is a law Sumba. that reflects values of life that a society embraces. To achieve national target indicators for Considering that changes are inevitable in any Maternal-Infant Health and to succeed Maternal- society and so are their value system, the challenge Infant Health Programs (MIHP)[4], the Central is thus to choose which values that will be adopted Sumba Regency requires Regional Regulation that as the very foundation of the law.[2] can prompt related sectors in maternal health Unfortunately, it seemed that to some degree program improvement, and govern the the value of life as reflected in the cultural practices implementation of Maternal, Infant and Child among the Central Sumbanese is not always Health Revolution in Central Sumba Regency to compatible with the goals of protecting pregnant enable the activation of inter-sectoral programs for women. In Central Sumba, pregnant women are rapid national target achievement. This Regional still required to do daily housework including the Regulation serves as the product of law that will harsh cultivation activities. Attention to and give the authority to implement Nusa Tenggara protection of pregnant women require Governor Regulation No. 42 of 2009 on Maternal improvement, since there's still a common belief Health Revolution in East Nusa Tenggara Province that it's normal for pregnant women to keep doing as a part of the efforts to reduce maternal mortality day-to-day works around the house despite their during labour, new-born mortality, and under-five condition. Dissemination to raise awareness about mortality. the importance of protection of pregnant women To provide legal protection for mothers, it is has been done; improvement, however, seems to be important to consider the nature of the relationship necessary between men and women and the gender injustice. To improve the maternal health, inter-sectoral Gender injustice and discrimination are imbalance collaboration is necessary. Depending exclusively and unequal or unjust conditions resulted from on the health sector would not be sufficient, and social structure system where men and women are assistance from other sectors would definitely be the victims of this system. Gender injustice occurs needed. Community empowerment needs to be as a result of beliefs and justifications instilled done by intensifying the involvement of village within the minds of the society and of individuals officials and inspiring more active involvement of in various forms. Manifestation of gender injustice the local community members. Instead of passively resulted from discriminations includes: waiting for programs arranged by the Puskesmas, marginalization, subordination, violence, and they should take a more active role in social double burden. Socialization to raise awareness activities, such as in Posyandu, becoming the about the importance of protecting pregnant women helping hand of Puskesmas and becoming nutrition has been done, however the tradition of pregnant cadres. For this reason, a precise budget allocation women doing housework practised from generation that will appropriately meet the needs is required to to generation still remains. Double burden imposed avoid the community from having double burden. to women, particularly in this case pregnant women

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that is roles and responsibilities to handle all sort of Article 2 and 3 of Law No. 36 of 2009, which read domestic works every day, still takes place. From the following: cultural perspective, many a time this double Article 2 burden is viewed as a form of dedication and noble Health development is administered sacrifice. However, endless sacrifices may lead to under the principles of humanity, injustice since it may jeopardise the health of balance, usefulness, protection, pregnant women, and worse, may lead to the respect to rights and obligations, mother's death during childbirth. justice, gender and non- When the state fails to provide adequate discriminatory, and religious norms. protection to institute the health of pregnant women Article 3 and women during childbirth, it is substantially Health development aims to improve marginalization to women needs; this will result in awareness, willingness, and ability of the exclusion of women from obtaining their right every individual to live healthy in to receive welfare, since the fulfilment of their order to realize the highest possible health right is not guaranteed. In a nation life, its health for the community, as an welfare is largely connected to the role the investment for the development of government plays in fulfilling the needs of mothers productive human beings, socially and as the citizens of the country, particularly in health economically. sector. In regard to this Barr (1987) stated that:[3] Establishment of local regulations containing The concept of the welfare state ... defies rules on maternal and child health is one of the precise definition. ... First, the state is not important parts of legal development at the local the only source of welfare. Most people level to provide protection for the rights and find support through the labour market for interests of mothers and children. The scope of most of their lives. ... Individuals can norms of such regulations needs to consider the secure their own well-being through necessity of providing integrated, comprehensive private insurance; and private charities, and qualified antenatal care, including pregnant family and friends also provide welfare. women's health and nutrition counseling, family Second it does not follow that if a service planning counseling and breastfeeding. The is financed by the state it must necessarily regulations also need to eliminate missed be publicly produced. ... Welfare is thus a opportunities for pregnant women to obtain mosaic, with diversity both in its source integrated, comprehensive and qualified antenatal and in the manner of its delivery. ... [T]he care; early detection of pregnancy abnormalities / term ‘welfare state’ can ... be thought of diseases / disorders, intervention against pregnant ‘as a shorthand for the state’s role in abnormalities / diseases / disorders as early as education, health, housing, poor relief, possible and referral cases to health care facilities social insurance and other social in accordance with the existing referral system. services’. Indicators used are coverage of 1st visit, coverage According to the World Health Organization of 4th visit, and complication handling. In addition, (WHO), health is a state of complete physical, other aspects that need to be clearly regulated in mental, and social well-being and not merely the the local regulation shall include: absence of disease or infirmity. Whereas, health The principles, objectives and scope of the local system based on law is one of the methods the State regulations need to be clearly defined to ensure the applies to fulfil the rights of its society. According relevance of regulations. Regulatory principles to Law No. 36 of 2009 on Health[5], health need to be laid down as the foundation for development is part of the national development regulation of various aspects of local regulations on which aims toward improving the awareness, maternal and child health (MCH). These principles willingness, and ability of every individual to live are intended to invigorate the norms contained in healthy, to realize the optimum health level for the the local regulations concerning the MCH services, community. This becomes the goals and principles so that the whole norms in the regulation of health development which are indicated in constitutes a united comprehensive norms bound

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by common principles. The relevant underlying of health services so that women have the principles includes humanity, balance, wholeness opportunity to undergo the process of pregnancy and continuity, benefit, protection, transparency, safely. justice, and non-discrimination. One important aspect affecting the quality of The rights and obligations of the parties related reproductive health is accurate knowledge and to the protection and improvement of MCHs information on reproduction systems, functions and should also be contained in local regulations on processes. Some subjects that need to be regulated MCH. This content reflects the rights held and the are the information management, health obligations that must be carried out by various monitoring, immunization, reproductive health parties within the framework of protection and education, gender equality and special job-related improvement of the MCH. Since the rights and treatment. duties are contained in a legal instrument, it is certainly to be understood that they are legal rights V. CONCLUSION and obligations that should be performed and The role of the state through a pro-mother legal fulfilled. development to bring maternal health into fruition In addition to the obligations of the local is regarded as highly necessary and pressing issue governments derived from higher legislation, the to actualize. The role of the regional government obligations of the other parties such as the general on the other hand as the extension of the central public, educational institutions, private sector government leaves the regional government as businesses, maternal health service providers that legal development's driving force that can help address the regulation of local regulations, as well decrease the maternal mortality rate. This role is as their families should also be properly regulated. achieved through harmonious legal formation at The management of Maternal Health Services central and regional level and enforcing the laws should also be included in the regulations. This that have been made (law enforcement). aspect covers the principles of the implementation of maternal health protection and improvement which is basically the obligation of the government. In addition to governmental ACKNOWLEDGEMENT obligations, the authority and responsibility of the Finally dedicated to Arie Siswanto, S.H., local government should be regulated as well. M.Hum., for being a good friend for the writer as The Protection and Improvement of Maternal discussion partner from the idea, concept until this Health needs to be regulated through provisions in article be a full well-written article. local regulations that focus on regulating maternal health services under various conditions. These REFERENCES conditions include the condition of the mother [1] Departemen Kesehatan Republik Indonesia, during pregnancy, childbirth and post-childbirth. Sistem: Bentuk dan Cara Pembangunan Reproductive Health is another important aspect Kesehatan Nasional Jakarta, 2009 that needs to be addressed in regulations. In general [2] B. Kusumohamidjojo. Ketertiban yang adil, reproductive health is a complete physical, mental Problematik Filsafat Hukum (A Just Order, and social condition, not only freedom from The Problematic of the Philosophy of Law). disease or disability in all aspects relating to the Jakarta: Grasindo Gramedia Widiasarana reproductive system, reproductive functions and Indonesia, 1999 processes. The issue of reproductive health is an [3] G. Bertram, Assesing the Structure of Small important link in a series of efforts to protect and Welfare States, London: Commonwealth improve maternal health. In that connection, there Secretariat and United Nations Research are some rights that need to be guaranteed in the Institute for Social Development, 2011. local regulations, such as the right of men and [4] Maternal Infant Health Program (MIHP) is women to obtain information and obtain safe, support program for pregnant women, new effective, and affordable access both economically parents and families from a team of public and culturally and the right to enjoy adequate levels health office, social workers, and nurses. [5] Law No. 36 of 2009 Concerning Health

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