"Safe motherhood", family planning and maternal mortality: an Indonesian case study.

This case study in Indonesia examined some assumptions about the outcome of family planning services. Safe Motherhood programs were flawed, because of the misplaced emphasis on family planning as a strategy to reduce maternal mortality. Family planning programs reduce the exposure to the risks of child-bearing, but they do not reduce the actual risks. Reproductive health should not be linked so tightly to demographic concerns and family planning. That cost saving occurs from family planning is insufficient to justify inattention to the needs of high quality obstetric care. Family planning should be viewed as just one component of a larger, comprehensive set of measures designed to assure the health of women at all stages in the life cycle: as citizens and workers, as mothers, and as adolescents. Interventions must begin before childbearing and include growth in economic, educational, and health opportunities. The aim of reducing maternal mortality by 50% by the year 2000 was included in Indonesia's five-year development plan: Repelita V. The example of Indonesia was important, because of its achievements in reducing poverty and increasing the standard of living of the population, and because of its large population size. Estimated maternal mortality in Indonesia was 450/100,000 live births in 1989, up from 390/100,000 in 1982. There was evidence from other studies that maternal mortality has increased. Criticism has been directed to the misplaced emphasis on family planning and the top-down delivery of professional services for ignoring local health-enhancing practices and the role of families, fathers, and communities as health providers. The realized cost effectiveness of family planning is an abstraction. Fertility has declined with an increase in family planning from 5.6 children to 3.0 children in 1990, but, for example, Bali has both high levels of contraception use and high maternal mortality. Integrated programs and the high risk approach have not been particularly successful.