Public-Private Partnership to
Increase Contraceptive Choice with
Socialization and Training of
Health Professional in the Use of
Emergency Contraception Pills
Prepared for the Catalyst Consortium
Johns Hopkins Center for Communication Programs
End of Project Report
Tifa Building 5/F
Jl. Kuningan Barat 26,
T: (62-21) 525 2174; 525 2183
F: (62-21) 525 1548
The STARH (Sustaining Technical Achievements in Reproductive Health) Program is a five-
year program funded by the U.S. Agency for International Development under Cooperative
Agreement No. 497-A-00-00-00048-00, effective August 22, 2000. The program is
implemented by Johns Hopkins Center for Communication Programs.
Any part of this document may be reproduced or adapted to meet local needs without prior
permission provided the material is made available free or at cost. Any commercial
reproduction requires prior permission from STARH. Permission to reproduce materials,
which cite a source other than STARH, must be obtained directly from the original source.
Suggested Citation: STARH Program. August 2005. Public-Private Partnership to Increase
Contraceptive Choice with Socialization and Training of Health Professional in the Use of Emergency
Contraception Pills – End of Project Report.
For more information on this report/publication, please contact Indonesia USAID office or direct inquiries to the
BKKBN Building I, 3rd floor
Jl. Permata No. 1, Halim Perdanakusuma
Jakarta 13650, Indonesia
Phone: (62-21) 525 2174, 525 2183, 801 6640; Fax (62-21) 801 6649
Please visit http://www.kbberkualitas.or.id to see other STARH Tools
The success of this project is due to the hard work of many people. The Indonesia ECP
Socialization Partnership gratefully acknowledges:
Catalyst : Zynia Rionda, Program Officer
USAID/Washington : Maureen Norton, CTO/Catalyst
Sonali Korde, Asia Near East Bureau
USAID/Jakarta : Monica Kerrigan, CTO/STARH
JHUCCP/Baltimore : Anne Palmer and Catherine Harbour, Program and Technical
STARH Team : Gary Lewis, Team Leader
Budi Harnanto, Finance Officer
Nurfina Bachtiar, Program Officer
DepKes : dr. Trisnawaty Loho
dr. Prastowo Nugroho
PT. Tunggal Team : Hendra Gunawan
Basuki Dwi Harjanto
JNPK (NCTN) : dr. Djoko Waspodo
PATH : Yanti Triswan
A special thanks you goes out to the 13 provincial training teams, representing DepKes,
PT. Tunggal and the Association of OB/GYN Indonesia. These teams visited 104
districts in their efforts to socialize ECP.
TABLES OF CONTENT
I. INCREASED METHOD CHOICE THROUGH SOCIALIZATION OF ECP............................... 1
1. Introduction ................................................................................................................... 1
a. Problem Statement ....................................................................................................... 1
b. History of EC in Indonesia.......................................................................................... 1
c. Policy and Program Environment for ECP............................................................... 2
d. Religious issues............................................................................................................ 3
e. Role of Midwives......................................................................................................... 3
2. Activities in Support of Increased Method Choice through Socialization of ECP. ....... 4
a. Media Socialization of ECP ........................................................................................ 4
b. Socialization and Skills Building of Health Professionals Workshops ................ 5
c. NGO Socialization of ECP .......................................................................................... 9
d. Summary of Outcomes ............................................................................................. 11
e. The Tsunami Relief Effort and Socializing Emergency Contraceptive Pills
(ECP) .................................................................................................................................... 13
f. Public-Private Partnership ....................................................................................... 13
g. Assessing Impact ....................................................................................................... 13
II. OPTIMAL BIRTH SPACING INTERVAL (OBSI) – A POCKET GUIDE FOR COUNSELORS 21
a. Implementation Process............................................................................................ 21
b. Findings from the Pretest ......................................................................................... 22
Appendix A – Service Delivery Guidelines
Appendix B – Pedoman
Appendix C – Translation of Islamic
Appendix D – Print Media Coverage
Appendix E – ECP Socialization Workshops
Appendix F – Images of Materials
Appendix G – Distribution List
End of Project Report
Public-Private Partnership to Increase Contraceptive Choice with
Socialization and Training of Health Professionals
In the Use of Emergency Contraception Pills
I. INCREASED METHOD CHOICE THROUGH SOCIALIZATION OF ECP
a. Problem Statement
Emergency Contraception Pills (ECP) can reduce the risk of pregnancy after
unprotected intercourse. ECP may be provided in two ways: using increased doses
of certain oral contraceptive pills, and there are branded hormonal pills packed and
formulated specifically as ECP. ECP can reduce the risk of pregnancy up to 120
hours after unprotected vaginal intercourse. They work best when taken within 72
hours — during this time they can reduce the risk of pregnancy by 75 to 89 percent.
According to the 2002/03 IDHS, 17% of births are the result of unintended
pregnancies, either because they are mistimed (9.5%) or because they are unwanted
(7.3%). Given that the number of children born in Indonesia each year is estimated
at 3.3 million, this means that there are roughly 550,000 pregnancies each year that
are either not wanted at the time they are conceived (310,000) or not wanted at all
Mistimed and unwanted childbearing are indicators of imperfect control over the
reproductive process. By giving couples access to good quality family planning
services, information and method choices to match their specific reproductive issues,
as many as one half unintended pregnancies could be prevented each year. If
Indonesia were to reduce unwanted pregnancies by half this year, it would mean a
2.2 TFR in 2005, close to the replacement level fertility goal of 2.01 by 2015. Use of
ECP could be a major contributor to meeting the development goals of Indonesia
and in improving the reproductive health of Indonesian women by increasing birth
intervals, and reducing unsafe abortion and high-risk pregnancies.
b. History of EC in Indonesia
Emergency Contraception (EC) using combined oral contraceptive was already
described in Indonesia national family planning documents in early 1991. However,
ECP was first introduced in 1996 by an Emergency Contraception Consortium. The
Consortium core team consisted of Pathfinder, PATH and WHO. Initially,
Pathfinder was responsible for leading the Consortium activities, including: service
delivery, training and monitoring. PATH was responsible for IEC material
development and communication strategies. WHO was responsible for the baseline
study and evaluation.
The first introductory symposium on EC was done at BKKBN in 1996. And in 1997,
WHO contracted out the baseline study in four provinces. Findings indicated that
knowledge about EC was very limited. Of the 35 policy makers and program
managers interviewed at the national and provincial level, only one third of them
and 25 percent of providers interviewed had heard of EC.
During the second phase of the EC Consortium activity in 1998, PATH took over
leadership. Regular meetings with key stakeholders were held to monitor activities,
policies, and regulatory approval of a branded EC. Ford Foundations joined the
Consortium and provided funding and critical policy advice. This phase of EC also
involved various government and non-government organizations including key
leaders of the Muhammadiyah Health Council, Fatayat NU, the Indonesia Islamic
Religious Leaders Council (MUI) and the Indonesia Society of Obstetrics and
In 1999, with funding from the W.A. Gerbode Foundation, PATH initiated a pilot
program to test service delivery for provision of ECP (Postinor-2®) among private
practice midwives (Bidan Praktek Swasta) in Central Java and Bali and in selected
family planning clinics. Four years after the application was filed, the levonorgestrel
ECP dedicated product Postinor-2 was registered and approved by Badan
Pengawasan Obat dan Makanan (BPOM) (the Indonesian FDA) on July 16, 2003.
c. Policy and Program Environment for ECP
Government policies around ECP are in a state of transition. ECP has been familiar
to family planning workers of several years, but has never had any official status.
The first trials in 1999 were done with approval from the Government, but little
active involvement. In 2003, the “National Family Planning Service Delivery
Guidelines” were issues and included a section on ECP. The Guidelines were issued
as the official and only standards for Family Planning service delivery by BKKBN,
DepKes, and the health professional organizations. BPOM gave approval for
distribution of Postinor-2 as an ethical drug in 2003, and the first launch events and
distribution of stocks started in early 2004. The Jakarta launch of Postinor-2 by its
commercial producer, PT. Tunggal was officiated by Ibu Sumarjati Arjoso, Head of
BKKBN has subsequently taken the position that ECP, while available and safe to
use is not part of the official program, that is – not a method that will be purchased
or actively promoted by BKKBN. BKKBN’s unwillingness to address ECP are based
on stated concerns that ECP might be politically sensitive. However, BKKBN does
consider informing providers about ECP to be part of its role in supporting a broader
method choice, and has been involved in developing provider messages.
DepKes has taken a more proactive position, through its “Making Pregnancy Safer”
strategy that considers unwanted pregnancy a major health risk to women, and a
burden to the health-delivery system. To support their proactive stand, DepKes has
incorporated ECP into its services, focusing on couples, family planning clients with
a method failure and victims of rape. DepKes has issued a new set of clinical
guidelines, expanding on the National FP Service Delivery Guidelines. (See
Appendix A). DepKes has also issued a pedoman stating the official policy of DepKes
and the role of Government health facilities in delivering ECP to clients. (See
Appendix B for a translation of the pedoman).
d. Religious issues
Religious sensitivities are always considered in any discussion of public policy. ECP
is no different. There is a long history of religious groups and leaders playing an
active role in supporting family planning. This history continues with ECP. The
clinical trials of a branded ECP in 1999 were done in health facilities associated with
Muhammadiyah (the largest Islamic social welfare group in Indonesia). The
Muhammadiyah Health Council managed the trials.
As part of the application for registration of Postinor-2 an Islamic scholar was
recruited to review the medical and social data in the context of Islam and provide
advice. Dr. Faturarachman Djamil did the study and came to the conclusion that
ECP was not in conflict with Islamic principles, and was an appropriate addition to
the family planning methods currently available. (See Appendix C for a translation
for the paper).
To register a new FP product, BPOM requires a review by the Majelis Ulama
(Indonesia Islamic Religious Leaders Council). The Council approved the
registration of Postinor-2, but expressed concerns about use by young people. This
lead BPOM to give approval conditional on monitoring of the distribution and sales
by PT. Tunggal, which the firm is doing.
e. Role of Midwives
The BPOM approved sales of Postinor2 as an ethical drug. Oral contraceptives are
also still on the ethical drug list. But long-term policy has been that midwives, the
major source of family planning services (about 75 percent), are allowed to issue
prescriptions for family planning products, including pills, injectables, IUDs and
implants. This policy has defacto been extended to include ECP.
In terms of access, socialization, and effective use of ECP the role of midwives is
§ Public and private sector midwives provide the majority of family planning
services in Indonesia.
§ They are a major source of family planning information.
§ Private practice midwives are affordable for most Indonesians, even the poor.
§ They offer the immediate access in cities and villages across the country – an
important consideration given the 72-hour period of effectiveness for ECP.
§ Many midwives already procure supplies from private sector sources, and an
additional method would not prove problematic for them.
§ The only other source for an ethical drug is a doctor, and doctors see few family
planning clients and rarely do the counseling or client education necessary for a
2. Activities in Support of Increased Method Choice through Socialization of
The interests of DepKes in reducing the health risk of women from unwanted
pregnancies, STARH’s interest in facilitating expanded contraceptive method mix, and
PT Tunggal’s interest in building a solid market for ECP and by association their
commercial product was greatly facilitated by the provision of a grant from the Catalyst
Consortium to develop ECP use for greater method choice. The result of this shared set
of interests were the ECP Socialization activities described in this Report.
a. Media Socialization of ECP
In preparation to socialize ECP to providers, socialization activities were carried out
to ensure the engagement and support of the media. The media were provided
information on ECP through the Journalists’ Forum, a group of health journalists
that meet regularly to proactively seek information on various health issues. The
Journalists’ Forum is a regular advocacy partner of STARH. The Forum met before
the Socialization Workshops began. This was to ensure that if any issues arose the
media would be aware of ECP and know where to go to get correct information.
Journalist participated from both print and electronic media. The presenters were
Prof. DR. dr. Biran Affandi and Dra. Maria Ulfah Anshor. Issues covered included:
A biomedical introduction of ECP, the social benefits of ECP, the Islamic position on
ECP, the critical information for clients in need of ECP. (See Appendix D for
examples of print media coverage).
b. Socialization and Skills Building of Health Professionals Workshops
Critical to the introduction of any new health product is a strong base of proactive
health professionals. This critical mass of professionals serves to market the product,
create awareness in the general population, build consumer confidence, provide the
product, resolve problems, and facilitate any additional health care the client might
need. Indonesia has taken the initiative to create a critical mass of providers to
introduce ECP to support the “cafeteria” of family planning choices currently
available, with a “Crash Program” of workshops to socialize and train family
planning providers. This Crash Program was implemented as follows:
§ The Catalyst Consortium provided a grant to the Johns Hopkins Center for
Communication Programs (STARH’s implementing agency). The funding for
the grant was provided by the Asia and the Near East Bureau (ANE) of USAID
as part of the Global Bureau grant to the Consortium.
§ The ECP partners – DepKes, PT. Tunggal, and STARH/PATH planned and
implemented a series of socialization/training workshops to introduce ECP to
providers in 97 districts across Indonesia.
§ The workshops were jointly sponsored and implemented by a public-private
partnership of DepKes, PT. Tunggal, and STARH.
§ The workshops addressed both Yuzpe (use of combination oral pills for
emergency contraception) and branded products. DepKes and STARH wanted
Yuzpe included because the workshops covered ECP, and use of combined pills
increases access and reduces costs for the poor. PT. Tunggal supported this,
since their interests were in desensitizing any concerns about ECP. Postinor 2®
was featured in the workshops as the only branded product registered and
available in Indonesia.
§ The number of provinces and districts selected to implement the Socialization
Workshops was defined by the budget available in the grant form Catalyst.
Eleven provinces were selected using several factors: population size,
innovativeness/leadership, ability to manage, existing distribution networks; and
DepKes priority areas. The districts (110) were selected from a list of districts
identified by the PT. Tunggal field offices as having a distribution outlet that
would ensure PT. Tunggal’s ability to continue to supply Postinor2®. The
existing network of distributors/detailers included: “KorWil” a provider who acts
as a depot for other providers in the area; apoteks (drug stores) that wholesales to
local providers; and regular drug “detailers” employed by PT. Tunggal. The
number of districts selected in a province was roughly proportional to the total
number of districts in the province. East and Central Java got fewer districts
because 10 (5 and 5) districts got ECP socialization using World Bank funding.
North Sulawesi, was one of the original 11 provinces, but did not respond to the
invitation. It was dropped and replaced by West Nusa Tenggara (NTB) and East
Nusa Tenggara (NTT). When an unannounced North Sulawesi training team
showed up at the training for provincial training teams in Yogyakarta, the
decision was made to increase to 13 the number of provinces covered and
redistribute the 110 districts.
§ Various options were considered for implementing the workshops. In the end
DepKes decided to use a cascade training model. A master-training team trained
the provincial training teams at the Yogyakarta workshop. These teams, in turn,
trained in all the district workshops in their province. This approach ensured
use of high quality trainers, consistency of message, better communication
between the district management teams and the provincial training teams, and it
left behind some follow-up training capacity in ECP. The training team running
the Yogjakarta master training included:
o Dr. Djoko Waspodo – Clinical trainer
o Dr. Suryono – Clinical trainer
o Maria Ulfah Anshor – from Fatayat NU on social and religious factors in ECP
o DepKes, Family Health Division – (Dr. Trisnawaty Loho, Dr. Sri Hermiyanti etc.) to
do a last review of content and materials before production; to work with provincial
teams on management and reporting; and to get familiar with the Workshop content
so they could provide quality control for the provincial training teams.
o STARH – Rusdi Ridwan as team leader; Tetty Sihombing to help teams with
advocacy and promotion of ECP; Budi Harnanto to train the teams and managers in
budgeting and financial reporting.
o PT. Tunggal – Pak Reza Abidin, President and Pak Basuki represented the private-
sector partner. PT. Tunggal had 13 provincial representatives there for the training
and to prepare them for participation in the provincial teams.
§ Each District socialization workshop was organized by the district office of
DepKes (DinKes). They set up the facility, coordinated schedules with the
provincial training teams, managed the funds to cover local costs, issued
invitations, and are responsible for any follow-on. To promote participation,
DinKes used formal invitation, their regular communication channels with
health facilities, and contacted district chapters of professional organizations.
The provincial DinKes also encouraged the district DinKes to fund travel for
Puskesmas bidans from local budgets. Given the large number of provinces, the
larger number of districts and the number of people involved, the management
and logistics for the Workshops went remarkably smoothly, and is a credit to the
DepKes Management Team.
§ Participation in the Socialization Workshop was designed to attract “early
adopters” by being self selecting and self financed (no “per diem” or travel
costs/allowances were paid to participants). The Catalyst grant was used to
provide facilities, audio-visual equipment, travel costs for trainers, and lunch for
participants. Participants included: Bidan (midwives) from health centers,
villages and private practices, Dokter Umum (General Practitioner) and selected
pharmacists. They were both public and private Family Planning providers.
Districts were encouraged to make a special effort will be made to recruit Bidan di
Desa (Village Midwives) as they are closest to clients and are most likely to be
able to support ECP use within 72 hours.
§ The content of the training included:
o Introduction to ECP product and Yuzpe.
o What is the problem (method failure and unplanned/unprotected
o How EC can help.
o What providers need to know
ü Not an abortafacient
ü Two choices - Product & Yuzpe.
ü Since ECP provides protection from the unplanned or unintended intercourse, it
is better to have ECP in anticipation of need rather than waiting until needed,
and seeking it curatively (see the umbrella in print materials as a metaphor for
ü Sooner used – more effective.
ü Effective if used in the first 72 hours after unprotected intercourse.
ü After 72 hours effectiveness drops to about 70% for 5 days. After 5 days it is
ineffective and contraindicated.
ü Use of ECP has no effect on the developing pregnancy.
ü Medical follow-up is needed to determine pregnancy status (not 100% effective).
ü Yuzpe formulations and dosage information
ü Local sources of product stock.
ü Avoid a missed opportunity – give every client at risk of a method failure or
unprotected sex, who does not want to get pregnant at that time a product or a
o What clients need to know
ü Two choices
ü When the client needs ECP
ü How to use ECP
ü 72 hours
ü Carry as insurance for unprotected intercourse or concerns about the
effectiveness of contraceptive method.
ü Seek medical care afterwards to confirm pregnancy.
§ The thirteen provinces participating in the ECP socialization workshop cover
about 70% of the population of Indonesia. Provinces include: West Java, Central
Java, East Java, DKI Jakarta, Banten, Yogyakarta, Bali, NTB, NTT, North
Sumatra, South Sumatra, North, and South Sulawesi.
§ Total participants who attended the Socialization Workshops in 104 districts (13
provinces) are 7,234 that are consists of 1,359 medical doctors, 5,080 midwives
and 795 others. The Socializations Workshops provided by NGOs (IBI,
Muhammadiyah and Muslimat) were attended by 145 midwives. Thus the total
official1 participants of all socialization workshops are 7,379. See appendix E for
Number of Workshop Participants
Source: District Health Office ECP Socialization Activity Reports
§ The Workshops had a fixed content and materials. However some of the
provinces modified the program to match their specific needs. The participants
were intended to be clinical family planning providers - midwives, general
practice doctors and selected pharmacists. In DIY and NTT, Family Planning
Field Workers also participated. In NTT, members of a women’s club (PKK), the
Catholic women’s organization, and the Muslim women’s organization also
participated. One of our future goals is to help socialize ECP with demand-
generation workshops for women-serving NGOs. NTT has already started this
process. In East Java some heads of district family planning offices participated
and started socializing ECP at the political level.
§ To provide quality control on the district workshops, ECP team members from
DepKes visited the first district workshop(s) in each province. This allowed
A lessons-learned, in fact, about 2 to 3,000 additional or unofficial observers attended the Socialization
Workshops. Seventy participants were used as an average for planning the budgets, and this average was
communicated to the trainers and managers in the provincial preparatory meetings. The expectation was
costs and demand would vary and so the number of participants would vary, but each district in the
province would have – on average – 70 participants. In the district reports almost every workshop had 70
participants. In fact, most of the Workshops had 70 registered participants and about 30+ “observers.”
Concerns about lack of interest or an unwillingness to self-fund were unwarranted as every session was
them to observe training, improve style and content, and address any issues not
covered in the Yogyakarta training:
o dr. Trisnawati supervised the workshops in Badung (Bali) and Yogyakarta (DIY)
o dr. Prastowo supervised the workshops at Minahasa Utara (North Sulawesi),
Semarang (Central Java), Surabaya (East Java) and Mataram (NTB)
o dr. Christine supervised the workshops in South Jakarta (DKI), Garut (Jabar),
Banyu Asin (South Sumatra), Pematang Siantar (North Sumatra), Takalar (South
Sulawesi), Belu (NTT) and Tangerang (Banten).
§ Materials provided to workshop participants, include:
o Pedoman ECP (Policy from DepKes) (re-printed by PT. Tunggal).
o Surat Keputusan (Instruction letter authorizing provider roles in ECP)
o Clinical Guidelines (purple book from DepKes) (re-printed by PT. Tunggal)
o The PT. Tunggal marketing folder with a fact sheet
o Handout information cards for clients (100 each) (Appendix F)
o Client information posters for facilities (Appendix F)
o Contact information if there are resupply problems (in presentation slides)
o Copies of slides used in presentations
c. NGO Socialization of ECP
§ Muhammadiyah & Muslimat
STARH already has a capacity building activity with the two largest faith-based
organizations involved in social welfare and specifically health. Support for the
two groups has included: an inventory of facilities and services offered,
Performance Improvement training and application, counseling training for
providers (including ECP), and facility-specific marketing of family planning
services. STARH continues to support the development of a quality-of-service
“certification” scheme, increased donor and Government support, strategies for
improving care of the poor, and building a strong management structure to
strengthen the network of facilities. ECP is a logical addition to the clinical
services provided by these two organizations. STARH supported these two
organizations in socializing the ECP to their facilities and services network.
Muhammadiyah/ ’Aisyiyah did their Workshop in Yogyakarta on May 1, 2005.
Muslimat conducted their Socialization Workshop in Surabaya on May 8, 2005.
o ’Aisyiyah, the women’s wing of Muhammadiyah has taken the lead in socializing
ECP among ’Aisyiyah/Muhammadiyah health providers. The ECP Implementing
committee is lead by Dra. Siti Munsringah from ‘Aisyiyah Central Office in
Yogyakarta. The ECP facilitators are dr. Heru Prajotmo, ObGyn Specialist (Dr.
Sardjito Hospital), dr. H. Latifah Haniem Mental Health Specialist (’Aisyiyah Health
and Enviromental Maintenance Bureau), and Hj. Hikmah Sobri (’Aisyiyah Center
Office). The first activity was the Socialization Workshop, which had 48 participants
− All Muhammadiyah MCH and general clinics in Yogyakarta
− All ’Aisyiyah Maternity Clinics in Yogyakarta
− All ’Aisyiyah Health and Enviroment Maintenance Bureau staff
− Team Leaders of ‘Aisyiyah in Yogyakarta
− Students of ‘Aisyiyah Midwife and Nurse School (STIKES),
− ’Aisyiyah Team leaders of Kabupaten Sleman
− ’Aisyiyah MCH Clinic at Moyudan
− ’Aisyiyah Maternity and General Health Clinic at Panggeran
− Muhammadiyah Maternity and General Health Clinic at Pakem
− Muhammadiyah Hospital at Bantul
− Muhammadiyah Maternity and General Health at Srandakan Bantul
− Muhammadiyah Maternity and Health Clinic at Parangtritis Bantul
− Muhammadiyah Maternity and Health Clinic at Sewu Galur Kulon Progo
− Muhammadiyah Maternity and Health Clinic at Wates Kulon Progo
− Muhammadiyah Maternity and Health Clinic at Nanggulan
− Muhammadiyah Maternity and Health Clinic at Wonosari Gunung Kidul
− Al Amin Maternity and Health Clinic at Gunung Kidul
o Muslimat ECP Workshop
The Muslimat ECP Workshop in Surabaya was attended by 50 participants, 25
managers and 13 Sub-districts managers from East Java, and 12 Muslimat staff in the
provincial office in Surabaya. The designated ECP facilitators are: dr Bambang
Trijanto, ObGyn Specialist (Dr. Soetomo Hospital), Dra. Hj. Uji Asiyah (East Java
Muslimat) and Sudarmanik (Midwife from Muna Anggita Hospital, Bojonegoro).
§ IBI Midwives ECP Workshop
The Indonesia Midwives Association (IBI) and STARH are collaborating on in a
number of areas including quality of family planning, organizational
development, advocacy and ECP.
IBI conducted ECP Socialization Workshop for Bidan Delima, the quality
midwife program, in Jakarta and West Java, on May 4, 2005 in Jakarta. STARH
Program and IBI had an agreement to first channel ECP through the Bidan
The general objective of the IBI Workshop was to link quality, reproductive
rights, informed choice, the risks of unwanted pregnancy and the role of ECP in
providing women an informed choice of methods. The IBI ECP Socialization
Workshop followed the standard ECP content used for the other workshops, but
also added broader issues of quality, responsibility, and rights. The specific
objectives from the terms of reference were:
§ To increase the midwives’ role in creating awareness of women’s reproductive
§ To increase the midwives’ role in creating public awareness of women’s health
§ To increase ECP use to prevent unintended pregnancies and abortion and related
§ To be able providing ECP counseling and services in their own practices.
The main workshop topics were:
§ Myths and Realities on the Working Mechanisms of ECP.
§ ECP From an Islamic Perspective
§ The Midwife’s Responsibilities in Preventing Unintended Pregnancy
§ Reproductive Health and Reproductive Rights
§ Current Reproductive Health Issues
§ Counseling for ECP
§ The Availability and Distribution of ECP
The participants came from DKI Jakarta (25) Garut, Sumedang and Bandung
(22). The resource people in this workshop were Prof. Dr. Gulardi Hanifa
Wiknjosastro ObGyn Specialist and dra. Maria Ulfah Anshor (Fatayat). The IBI
facilitators were: Indra Supradewi, Hubertin Sri Purwanti , Dra. Yumiarni Ilyas
Mkes, Mustika Sofyan, Wastidar Musbir, and Oom Suryamah.
The participants who were invited are those who had not already participated in
the ECP Socialization in DKI Jakarta or West Java. The participants were asked
to prepare an activity plan for meeting client needs for ECP. Copies were to be
sent to IBI Secretariat. Certificates were awarded to the participants.
d. Summary of Outcomes
The following is a brief summary of the outcomes of ECP activities funded by
Catalyst and partners, compared against the proposed outcomes (in Italics)
§ Socialization among providers of the role and importance of ECP as a support for regular
The Workshops funded in this project had about 7,300 official participants. Most
were health professional. These people came from 13 different provinces and
represented 104 districts. All of the major health professional groups (IBI, POGI,
IDI) participated as trainers, participants, or implementers. The two largest
faith-based social welfare organizations in Indonesia sponsored socialization
workshops for management and medical staff. Since the project had broad reach
and wide acceptance, we should be approaching a critical mass of professional
and social support for ECP.
§ Get providers to recognize and promote ECP as a preventive health tool rather than a
curative response to an unprotected intercourse or a suspected method failure.
The preventive role of ECP was covered in the Workshop. The Field Assessment
(see page 14) found that among the small number of participants interviewed
that are informing clients about ECP, and some are carrying stocks, so they are
prepared. But many are still prescribing and still waiting for clients to have a
problem before making an intervention. While progress was made, ECP does
not yet have the same preventive status as condoms or the umbrella (symbol or
materials). However, the sales data suggest providers are stocking supplies and
that suggests they are supporting an easier access.
§ Expand access to ECP.
The public-private partnership between DepKes and PT Tunggal has encouraged
both to support expanded distribution of ECP. The knowledge of Yuzpe was
also low among providers, so those parts of the Workshops should increase a
provider’s willingness to encourage clients to use oral pills if they should need
emergency contraception. The lack of problems encountered by the socialization
workshops is also making everyone involved more confident that ECP has a role
in ensuring method choice in the future. The utility and application of ECP in
the huge Indonesian market has been recognized, and another pharmaceutical
firm is doing use trial in preparation to register another branded ECP product.
§ Generate policy change that will support the role of ECP.
To support this activity DepKes took three important policy actions. It issued a
Surat Keputusan, the authorization for ECP to be provided in the health system; it
prepared expanded service delivery guidelines defining the appropriate use of
ECP, and providing the clinical information needed by providers; and it issued a
Pedoman stating the official policy of DepKes on ECP. DepKes has also made a
defacto policy decision to expand the authority for midwives to prescribe
contraceptives to include ECP.
§ Create an awareness of the risks of unwanted pregnancies and the role of ECP in
supporting regular contraceptive use in reducing unwanted pregnancies.
The Field Assessment suggests that providers clearly got the message that ECP is
to augment regular family planning methods and that it provided a necessary
alternative to unwanted pregnancy and abortion.
§ Support expanded private-sector roles in meeting the reproductive health needs of
The partnership between PT. Tunggal and DepKes has been very good. There
were initial concerns on working with the private sector at higher levels of
DepKes, but the effectiveness of the partnership soon calmed those concerns.
ECP is now used in DepKes as an example of working with the private sector.
One of the concerns was the appearance that DepKes was promoting a
commercial product. But this concern was addressed in the Workshops by
including Yuzpe, and the discussion of Postinor-2® being the only commercial
product currently approved for use in Indonesia.
§ Support the already major shift of consumer perceptions of family planning as a
government subsidized program to a self financing responsibility of the family.
This is a long–term objective and there is no clear indicator of impact yet.
e. The Tsunami Relief Effort and Socializing Emergency Contraceptive Pills (ECP)
STARH was asked by USAID to help rebuild family planning services in Aceh
Province after the December 26, 2004 Tsunami. In coordinating with other agencies,
STARH found that UNFPA disaster kits for RH/FP were being distributed by the
Government and the international agencies involved in providing medical care in
the camps and communities. These kits included ECP. Since these kits are generic
they do not include any materials for providers or clients. There was a need for ECP
because health workers reported considerable demand to address unplanned and
unprotected sex. While there was a need, few health workers or couples had
experience with ECP. Most of the external emergency health teams knew about
ECP, but did not speak Bahasa Indonesia, and could not counsel clients on why or
how to use ECP. Coincidentally the ECP partnership had produced a number of
informational pieces and the policy and clinical guidelines for the socialization
workshops. These materials were shipped to Aceh province and were distributed to
providers using the UNFPA Reproductive Health Kits by UNFPA, STARH and the
International Red Cross. PT. Tunggal printed more copies to replace those used in
supporting the communities devastated by the Tsunami
f. Public-Private Partnership
One of the more unusual aspects of the ECP Project was the shared reasonability for
socialization. The private sector, interested in creating a market for ECP, was willing
to produce materials, support media advocacy, provide data on their
marketing/distribution systems (to allow site selection), provide staff time and fund
travel costs so staff could participate in all district and NGO workshops, and finally
they provided sales data to assess impact. They were also able to take action when
problems arose in the field and training was not effective (West Java). All partners
participated fully, shared information, and focused on the goal of socializing ECP.
DepKes, STARH and PT Tunggal all worked closely, and the success of the
partnership is reflected in the large number of workshops held in widely dispersed
area, in a brief period of about four months.
g. Assessing Impact
The ECP Socialization Workshops are being assessed using three sources of
information. The first is Postinor 2® sales data. PT. Tunggal has made three
monthly provincial sales figure available. If the Workshops are effective we would
expect to see increases in sales beyond the trend of increasing sales. The sales source
of information is field assessment, where evaluators interview participants and
members of the district management team (usually Dinkes chief). The third source
will be an “Omnibus” Survey. The Omnibus is a marketing survey run every
quarter by AC Nielsen. The Omnibus allows us to put in question for a flat fee. The
Omnibus is not a very precise measurement tool since it is an urban sample and
interviews household consumers. It does, however, give us population exposure
data on a regular basis and at a low cost. Because of the timing of the Workshops,
the baseline was done in July and the follow-up will be in October 2005.
PT. Tunggal Reported Sales Figures
PT. Tunggal provided the Partnership ongoing sales data for Postinor 2. The sales
figures represent sales to providers by the various PT. Tunggal distributors. There
are no data on sales to clients. The trends in sales are represented in the figure
Postinor-2 Sales by Provinces
March - July 2005
Jakarta Banten West Java Central Java DIY East java Bali Makassar Palembang North North
Source: PT Tunggal Idaman Abadi
Comparison Postinor-2 Sales
Between 3 Provinces with Socialization and 3 Non Socialization
March - July 2005
Central Java East Java Bali West Sumatra Riau Lampung
Provinces with Socialization Provinces Without Socialization
Source: PT Tunggal Idaman Abadi
To facilitate understanding of the impacts of the ECP Socialization Workshops we have
provided Postinor 2® sales data for three provinces that did not participate in the
Socialization Program. DO NOT compare the levels, but do note the trends. The sales
levels are not relevant because of the differences in population since between the
provinces. Also, socialization of ECP started earlier in East and Central Java, using
World Bank funding. The trends lines in the non socialization provinces is flatter and
does not show the overall increases of the socialized provinces.
Gantt Chart of Provincial Timing of ECP Socialization Workshops
April May June
1 2 3 4 1 2 3 4 1 2 3 4
The above trend data provide a very clear picture of the impact of the ECP
Socialization Workshops. You can look at the trend and get a pretty accurate
estimate of when the workshops were held. To confirm this, a Gantt below provides
the timings of Workshops by province. The sharp rise in sales to providers reflects
the “filling of the pipeline,” as provider purchase stock to sell. The subsequent drop
off in sales reflects a full pipeline and the beginning of retail sales.
It should be noted that these data are totals for the province. The socialization
workshops were in a limited number of districts in each province. If the sales trends
were just for the districts with workshops the changes would be more extreme.
Also these sales data would not reflect any uptakes in the use of Yuzpe. Given the
cost and wide availability or oral contraceptives there is likely to be a similar or
greater uptake in use of orals for emergency contraception.
In order to get some understanding of how the Socialization Workshops operated
and the potential impact on health providers, a follow-up assessment was done.
STARH staff (Siti Sulami and Susan Meity) selected three provinces and one district
to visit. They interviewed providers who attended the workshop and the district
managers from DinKes. The assessment visited three districts out of the 104 that
participated in ECP socialization, so caution should be used in over generalizing the
results. The Assessment is being used to identify issues that any future efforts at
socialization should consider. The assessment was done after the workshops were
completed and participants had enough time to use the materials and presentations.
This meant field work was done in July and that there was insufficient time for a
deeper assessment before the end of the Project. Field-interviews were done in East
Java, Central Java, and North Sumatra.
The issues raised by the participants in the Assessment are summarized below:
§ Most of the ECP Socialization Workshop participants were DepKes staff
recruited from Puskesmas. This represents probably the biggest failure in
implementation. The plan was to give village midwives priority for
participation, since they are the closest to clients who might need ECP. The other
goal for participation was to get early adopters by letting them self select on their
interest in participating. Since DinKes was managing each district workshop, it
is probably not surprising that their invitation network and priorities favor
midwives and doctors in the puskesmas. Future socialization efforts might want
to consider districts doing different workshops for different groups or that other
networks (IBI, BKKBN, IDI) are given an allocation of seats in the workshop.
§ Participants asked to comment on the quality of the Workshops used the
following terms: the presentations were professional, clear and easy to
understand. The venues ranged from good to acceptable. The overall
organizations were good. The half day was just about right for the content. The
materials distributed were very useful.
§ A midwife from Tanah Tinggi North Sumatra reported: I put the poster up and
many of my clients asked about Pil Kondar. I wanted to answer their questions
carefully, so I opened - again and again - the handouts. I am now very sure I can
explain ECP very clearly.
§ The knowledge provided in the Workshops was described as “new.” Some had
some knowledge of Yuzpe, but the branded product was new to the
§ Participants reported a much greater willingness to provide ECP after the
Workshop. Some carried a stock, while others provided by prescription.
§ The justifications given for using ECP included: couples who have had an
unwanted pregnancy and are at risk of another; clients who have problems
staying on schedule with their regular method (pill and injectable); to
prevent/reduce abortions; for clients who can not use other methods for religious
reasons (???); and rape.
§ Because they could do something for clients who had a method failure or
unplanned intercourse they felt much more willing to counsel clients on these
§ There was a general preference for using the branded product because it was
more “practical” (“better quality”) than Yuzpe.
§ Some midwives were stocking Postinor2 for distribution to clients. One issue
raised in stocking was that client awareness and demand is low. There were
suggestions that there needs to be client socialization. Most seemed to get that
they had a role in educating clients on ECP, but some seemed to miss that point
that it should be done before it is actually needed.
§ Most providers expressed concerns about misuse, primarily by young adults.
They recommended that it be available only from midwife or doctor.
§ One goal of the workshops was to position ECP as a preventive health product,
and get providers to distribute it in anticipation of the client needing it.
Provider-opinion seemed mixed on using ECP curatively (by getting from the
provider after the fact) or preventively (having it in the home). The preventive
model does make ECP much more client-choice friendly. The preventive model
will need to be continuously reinforced to providers.
§ Providers report counseling clients on ECP was well received, and generated no
problems or negative reactions from clients.
§ Clients who would benefit from ECP still do not visit the provider within 72
hours. This stresses the importance of providers counseling all clients, and
having the method available.
§ Providers reported that Postinor2 was still not widely available when she gave a
client a prescription.
§ Providers did not feel ECP was an alternative to the regular methods of family
planning, and did not promote it as such.
Issues raised by the District Health Managers (DinKes) are summarized below:
§ The quality of the workshop was very good and participants were satisfied.
§ The budget was insufficient to do it as well as they would have liked.
§ There were requests for copies of the PowerPoint slides.
§ A couple of the districts would like to continue with the socialization. One is
talking to IBI about helping implement.
§ Managers were asked if DinKes would support ECP socialization and use. The
response was that since budgets are giving priority to the poor, and there was
insufficient funding to serve the poor, a new or expensive method was unlikely
to get government subsidies.
Again, caution should be used in over-interpreting these reports. However they do
suggest that DepKes and the ECP partners need greater focus on:
§ The need for continuing education about ECP and other methods by the
provider, in case the client needs it in the future.
§ Client knowledge of ECP is very low. This is reflected in the interest generated
§ Midwives and doctors need to stock the method rather than sending a client off
with a prescription.
§ Those midwives that are still treating ECP as a curative intervention rather than
a preventive reproductive health product.
Omnibus Survey ACNielsen
To get a measure of exposure to ECP, two questions were asked on the ACNielsen
Quarterly Omnibus Survey. The questions were fielded in early July, and will be
fielded again in September. The questions use Postinor2® as a proxy indicator of
recognition of ECP.
The two figures below confirm the low level of consumer knowledge of ECP. Since
Postinor 2® is relatively new, and the socialization process had finished only a
month earlier, low levels of knowledge are to be expected.
PERCENTAGE WOMEN WHO KNOW POSTINOR 2 BY SES IN OMNIBUS SURVEY JULY 2005
A : 1750 + B : 1250 -1750 C : 600 -1250 D: 400-600 E: 400 LESS
FAMILY MONTHLY INCOME
PERCENTAGE WOMEN KNOWING POSTINOR 2, MENTIONED ITS MAIN BENEFIT
45 0 PHARMACY MEDICINE
24 MORNING PIL
63 FAMILY PLANNING
JKT SBY MDN BDG SMR
Among the small number of women who knew about Postinor 2® the majority
actually knew its purpose was family planning (Jakarta 87%, Surabaya 100%, Medan
84%, Bandung 80% and Semarang 53%). The question is very basic so it is impossible to
see if respondents know it is a post-coital method of contraception.
II. OPTIMAL BIRTH SPACING INTERVAL (OBSI) – A POCKET GUIDE FOR
The Catalyst Consortium expanded to IEC Socialization Scope of Work to include
addressing birth intervals in Indonesia by producing and distributing the “Optimal
Birth Spacing Interval: an OBSI Pocket Guide”. This job aid for health and community
development workers was developed by Catalyst based on new analysis of world wide
Demographic and Health Survey data. The finding were and the message is 3 to 5 (year
birth intervals) Saves Lives. STARH has put the OBSI Pocket Guide into use in
Indonesia, and the process is described below:
a. Implementation Process
§ Adaptation - Catalyst provided a model Pocket Guide for STARH to use. The first
step was to create a working draft of the Pocket Guide that was relevant to the
Indonesian situation (by Gary Lewis, STARH). This version was modified to use the
Indonesian community and reproductive health field infrastructure language. It was
also edited to reduce the text to a minimum. This was done by using more bullets
and editing. Indonesia is still a verbal culture, so written information has less an
impact. In printed materials that are to be used in their entirety-less is better. The
adapted version in English was reviewed by several professionals from STARH and
§ Translation – the Guide was translated into Bahasa Indonesia by a professional
translator (by Bambang Wijatmiko, STARH). The translation then underwent
several internal reviews for language and message impact within STARH (Mayun
Pudja, Tetty Sihombing, Christie Natasha, Nurfina Bachtiar, Rusdi Ridwan). When a
consensus version was produced it was circulated to partners in BKKBN and
DepKes (Dasep B. Abadi, BKKBN and Trisnawaty Loho and Prastowo, DepKes).
Their reviews added additional refinement on wording and context.
§ Graphics and Layout – Once a translated version of the Guide was available, the
graphics and layout were done (Harimawan Latif, STARH). This version also went
through internal and external review before being “finalized.”
§ Pre-test - The OBSI Pocket Guide was pretested with full color and graphics in focus
group discussions in the Cianjur District (West Java) BKKBN Office. Participants
were 19 local village midwives (Bidan di Desa). The village midwives were used for
the pretest because they are the least educated midwives, and they are the most
likely to benefit from the OBSI Guide. The goals of the pretest were:
§ To test the providers’ comprehension on the words, phrases and concept in the
§ To get the providers’ reactions and perceptions of the utility, and the appearance
of the Guide (layout, colors, photos, print, etc.).
§ To test the providers’ ability to use the messages in the Guide.
The Guide was sent out to the participants in advance so they would have time to
examine and use it.
§ Production – After a competitive procurement, the printing contract was awarded to
Subur Printing. Catalyst reviewed the printing proposals, and made selection based
on cost. This printer has been the STARH “house” printer for the last year because
of their lower cost, consistent quality, and ability to meet deadlines. Originally
Catalyst was going to pay for production and printing. However, it was easier to do
the production in-house, with STARH funding, and this freed up budget so Catalyst
authorized STARH to pay for printing. With extra funding and a better price from
the printer STARH was able to print 168,000 copies of the Guide2.
§ Distribution – STARH has distributed 90,600 copies of the Guide as of August 20,
2005. Distribution is being done through several STARH partners. See Appendix G
for the first round distribution list.
b. Findings from the Pretest
§ The midwives wanted the sections under “Opportunity for Providing Counseling on
OBSI” to follow the chronological order of pregnancy and maternal care. The order
suggested was :
1. Antenatal Care (1)
2. Postpartum Care (3)
3. Amenorrhea Lactation Period Care (2)
4. Miscarriage/ Post Abortion Care (6)
5. Baby/Infant Period Routine Check-up, Immunization and Posyandu
(Integrated Health Post) (4)
6. Family Planning Services (5)
7. Community Outreach (7)
( ) original order
§ The phrase “during counseling don’t forget to:...” should be added on the topic of
Field Counseling during Community Outreach.
§ Most of the inputs were on wording and phrasing. The general effort was to use less
technical words and usually more common words and phrases.
The number of Guides printed is unusual for a donor or the Government. When, however, one considers
the number of midwives (≈ 100,000), FP field workers (≈ 20,000), FP Volunteer Cadre (≈ 50,000), and
other community leaders the number does not seem so large. The gap between what is produced and what
is needed to reach the intended audience in Indonesia is huge. This regular underproduction of materials,
and the failure to produce sufficient numbers to provide replacement or to supply new professional has lead
to a culture of poverty among field workers. This was highlighted in the OBSI pretest when midwives
suggested changes that would facilitate copying. The Guide was not even printed, and they were preparing
for the day when it would not be available.
§ The midwives found the Guide interesting and the messages relevant to their
§ The type and size of the text was appropriate and easy to read.
§ They suggested not using color gradations on the pages (light to dark) because it
makes the text less clear and it does not photocopy well. The colors representing
health, such as green, blue and yellow, are useful in highlighting the different topics.
§ The pictures should use “typical” rural Indonesians.
§ The midwives advised producing a version of the Guide that lended itself to
photocopying, because it would travel well in areas with no access to the ”good”
version of the Guide.
§ The invitation letter had information on why longer birth intervals were important
taken form the Population Report ”Birth Spacing - Three to Five Saves Lives.” The
participants found the mortality ratios very compelling and suggested they be put in
as an Introduction. This was done.
Yang dimaksud kontrasepsi darurat adalah kontrasepsi yang dapat mencegah keha-
milan bila digunakan segera setelah hubungan seksual. Hal ini sering disebut “Kon-
trasepsi pascasanggama” atau “morning after pill” atau “morning after treatment”.
Istilah “kontrasepsi sekunder” atau “kontrasepsi darurat” asalnya untuk menepis
anggapan obat tersebut harus segera dipakai/digunakan setelah hubungan seksual
atau harus menunggu hingga keesokan harinya dan bila tidak, berarti sudah terlam-
bat sehingga tidak dapat berbuat apa-apa lagi. Sebutan kontrasepsi darurat me-
nekankan juga bahwa dalam cara KB ini lebih baik dari pada tidak ada sama sekali.
Namun tetap kurang efektif dibandingkan dengan cara KB yang sudah ada.
Tabel 10-1: Jenis kontrasepsi darurat
Cara Merek dagang Dosis Waktu pemberian
I. Mekanik Copper T satu kali dalam waktu 7 hari pascasang -
AKDR-Cu Multiload pemasangan gama
II. Medik Microgynon 50 2 x 2 tablet dalam waktu 3 hari pascasangga-
Pil kombinasi Ovral ma, dosis kedua 12 jam kemudian
dosis tinggi Neogynon
KONTRASEPSI DARURAT U-55
Cara Merek dagang Dosis Waktu pemberian
Dosis rendah Microgynon 30 2 x 4 tablet dalam waktu 3 hari pascasangga-
Mikrodiol ma, dosis kedua 12 jam kemudian
Progestin Postinor-2* 2 x 1 tablet dalam waktu 3 hari pascasangga-
ma, dosis kedua 12 jam kemudian
Estrogen Lynoral 2,5 mg/dosis dalam waktu 3 hari pascasangga-
Premarin 10 mg/dosis ma, 2 x 1 dosis selama 5 hari
Progynova 10 mg/dosis
Mifepristone RU-486 1 x 600 mg dalam waktu 3 hari pascasanggama
Danazol Danocrine 2 x 4 tablet dalam waktu 3 hari pascasangga-
Azol ma, dosis kedua 12 jam kemudian
* Postinor-2 (750 mg levonorgestrel/tablet) telah disetujui oleh Badan POM untuk didistri-
busi- kan dan dipakai di Indonesia, Juli 2003.
• Sangat efektif (tingkat kehamilan < 3%).
• AKDR juga bermanfaat jangka panjang.
• Pil kombinasi hanya efektif jika digunakan dalam 72 jam sesudah hubungan sek-
sual tanpa perlindungan.
• Pil kombinasi dapat menyebabkan nausea, muntah, atau nyeri payudara.
• AKDR hanya efektif jika dipasang dalam 7 hari sesudah hubungan seksual.
• Pemasangan AKDR memerlukan tenaga terlatih dan sebaiknya tidak digunakan
pada klien yang terpapar dengan risiko IMS.
Indikasi kontrasepsi darurat adalah untuk mencegah kehamilan yang tidak dikehen -
• Bila terjadi kesalahan dalam pemakaian kontrasepsi seperti:
– Kondom bocor, lepas atau salah menggunakannya.
– Diafragma pecah, robek atau diangkat terlalu cepat.
– Kegagalan sanggama terputus (misalnya ejakulasi di vagina atau pada genitalia
U-56 KONTRASEPSI DARURAT
– Salah hitung masa subur.
– AKDR ekspulsi.
– Lupa minum pil KB lebih dari 2 tablet.
– Terlambat lebih dari 2 minggu untuk suntik KB.
• Tidak menggunakan kontrasepsi.
• Hamil atau tersangka hamil.
• Mual, muntah: perlu konseling. Jika muntah terjadi dalam 2 jam sesudah penggu-
naan pil pertama atau kedua, dosis ulangan perlu diberikan.
• Perdarahan/bercak: sekitar 8% klien dengan kontrasepsi oral kombinasi menga-
lami bercak-bercak. Sekitar 50% mendapat haid pada waktunya bahkan lebih
June 2004 Unofficial Translation
Ministry of Health
Policy and Strategy (Pedoman)
Using Emergency Contraception
The Maternal Mortality Rate in Indonesia is 307 every 100,000 live births, still the highest among
South East Asian countries. Complications related to pregnancy and delivery are the main causes
of maternal deaths. The age when pregnancy starts and stops, spacing of births, the number of
pregnancies during life, and socio-cultural and economic condition in which the woman lives, all
influence the morbidity and mortality experience of pregnant women. In Indonesia,
hemorrhaging is the main cause of maternal death, but there are other causes of death, such as
abortion complications (10-15%).
Even though around 90 % of countries in the world have policies to allow legal abortions for
reasons like to save the mother’s life. Still a considerable number of abortions are self-induced or
done by woman herself or done unsafely by unskilled providers. These unwanted pregnancies
cause death or permanently physical disability for women.
Making Pregnancy Safer strategy (of Indonesia) is a health strategy to accelerate the decline in the
Maternal Mortality Rate. Its third key message is that - every woman in the fertile ages has access
to service to prevent the unwanted pregnancy. The Family Planning program that has been
implemented has been by encouraging the provision of quality services. However we still find a
drop out rate of 20.7% (consisting of method failure 2.1%, want to get pregnant 4.8%, switch to
other methods 9.0%, and other reasons 4.8%, unmet needs 8.6% (consisting of a stopped giving
birth 4.6% and birth spacing 4.0%), and pregnancies with the 4 Toos (too young 0.2%, too old
13.5%, too frequent 8.0% and too many 6.7%). Those particular conditions cause unwanted
pregnancies, and lead to abortions.
It is expected that around two third of all unwanted pregnancies end with abortions. From these
facts, we realize that a routine contraception program is not enough. So we need to develop and
expand the currently Family Planning program to help these women overcome their problems.
This is in harmony with the ICPD Cairo 1994 appeal, where one program action is to decrease
the number of deaths and illnesses caused by unsafe abortions, in order to improve health of
women. It is also stated that abortion should not be recommended as family planning method;
that the commitment to the women’s health should be strengthened; that the tendency toward
abortion should be decreased by, providing expanded and completed Family Planning services.
It also stresses prevention of unwanted pregnancy as the highest priority to completely remove
the need for abortion.
Emergency Contraception can be a back-up and additional method in efforts to decrease the
incidence of these unwanted pregnancies, making a significant contribution to accelerating the
decrease in Maternal Mortality Rates.
1. General Objective
The decrease in the incidences of unwanted pregnancy through provision of Emergency
Contraception services to support the national Make Pregnancy Safer Strategy, and in order
to accelerate the decline of Maternal Mortality rates and to achieve the a “Healthy Indonesia
2. Specific Objectives
1. Directing the managers of the FP program on the development of Emergency
2. The development of emergency contraception services will be implemented
efficiently and integrated with related sectors.
The implementation of Emergency Contraception policy will refer to the general policy of
1. Providing Emergency Contraception services to the women in order to fulfill:
Reproductive Rights, Gender Equity and Gender Justice.
2. Improving women health and safe motherhood through preventing unwanted
3. Extending access to Emergency Contraception services.
Some alternative strategies that can be used in the implementation of the above policy are as
1. Will strategic advocacy efforts be in each administrative level to support the
implementation of Emergency Contraceptive services?
2. Will Emergency Contraceptive service be available in every health service point of
3. Will IEC and counseling for every couples and candidate for FP be through health
providers, cadres, and/or through selected media?
4. Will EC target all couples and engaged couples (who may need shortly)?
5. Is Emergency Contraceptive available only with prescription or can be bought over the
6. Who can supply Emergency Contraceptive?
- Donor agencies
- Private Sector
7. Should EC be part of programs to support victims of sexual violence (i.e. PP – KTP NGO
address violence against women)?
8. Training of trainers (TOT) in the district level.
9. How can there be an integrated strategy among government, donors and private sectors?
10. Research plan to support the development of services, for examples:
a. The effectiveness providing Emergency Contraceptive prophylactic (before
having method failure or unprotected coitus)
b. The potential misuse by young adult.
c. Emergency Contraceptive Pills (ECPs) vs. Abortion issues.
The successful of Emergency Contraceptive to reduce the incidence of Unwanted Pregnancies
can be shown by some strategic indicators as follows:
A. Direct Indicators:
1. Unwanted Pregnancies Rates
2. Abortion Rates
B. Indirect Indicators:
1. Contraceptive Failure Percentages
2. Pregnancy Rates with the “4 Toos”
3. Contraceptive Prevalence Rates
The implementation of Emergency Contraceptive Service needs an effective strategy. Even
though we want service to be easily available for clients, on the other hand we are also afraid
the teenagers will misuse the service. To make Emergency Contraception difficult to get is
not a good solution. For this reason, we need a good inter-sectors collaboration to make this
service available to those who really need it.
Pros and Cons in this service need to be considered in order to make this service really
accepted by all level of society.
26 Oktober 2004
Alkon Darurat untuk Keadaan Darurat
''Saya heran, kok bisa ya saya hamil? Padahal saya menggunakan IUD. Malah saya sudah
memakai IUD bertahun-tahun,'' ujar seorang ibu berusia 36 tahun di Bogor, Jawa Barat.
Kejadian ini tak hanya menimpa ibu lima orang anak itu. Kehamilan bisa saja terjadi meskipun
pasangan suami-istri sudah menggunakan salah satu jenis alat kontrasepsi (alkon). Di Amerika
Serikat (AS) sebanyak 48 persen dari enam juta kehamilan tak diinginkan terjadi karena
kegagalan kontrasepsi. Sisanya terjadi karena tak menggunakan kontrasepsi. Selain itu,
kehamilan tak diinginkan terjadi pada empat dari lima kehamilan remaja AS karena tak
menggunakan alkon. Sebanyak 60 persen kehamilan tak diinginkan berakhir dengan aborsi.
Di Indonesia pasangan usia subur yang tak menggunakan alkon sebanyak 10-11 persen, atau
lebih dari empat juta pasangan. Dari jumlah tersebut, sekitar 90 persen mendatangkan
kehamilan. Penggunaan alkon memang tak bisa dijamin 100 persen berhasil mencegah
kehamilan. Tingkat keberhasilan tergantung pada keadaan fisik dan kedisiplinan pengguna dan
pasangannya. Kehamilan bisa saja terjadi bila ada kelalaian dalam aturan penggunaan alkon.
Karena itu, ada metode alkon darurat (kondar).
Kondar merupakan alternatif praktis untuk mencegah kehamilan. Metode ini digunakan tiga hari
setelah berhubungan seksual tanpa alat pencegah kehamilan. Menurut data yang dikumpulkan
Koalisi Untuk Indonesia Sehat (KuIS), metode kondar bisa menurunkan sedikitnya 75 persen
risiko kehamilan pada wanita. Bila seratus wanita berhubungan seksual tanpa alkon, sekali pada
minggu kedua atau ketiga siklusnya (ovulasi), delapan orang di antaranya akan hamil.
''Meskipun perlu, kondar tak disarankan untuk digunakan dalam jangka panjang guna
mencegah kehamilan. Darurat memang hanya untuk sekali-kali saja bila sangat dibutuhkan.
Alkon biasa tetap digunakan bagi pasangan yang berkeluarga,'' kata Prof DR dr Biran Affandi
SpOG (K), ketua Program Pasca Sarjana Kesehatan UI dalam Forum Jurnalis yang digelar KuIS,
di Jakarta, beberapa waktu lalu.
Lebih jauh ia mengemukakan, kontrasepsi biasa jauh lebih efektif daripada kondar. Metode ini
diperlukan bila memang ada kealpaan atau kejadian yang tak bisa dihindari lagi. Salah satu
contoh adalah pada para korban perkosaan. Di sini kondar sangat dibutuhkan. ''Makanya, saat
ini di pusat-pusat krisis kondar sudah tersedia,'' ujarnya.
Kontrasepsi darurat antara lain terbuat dari tembaga, pil KB (progestin, estrogen), mifepristone,
dan danazol. Alkon biasa pun bisa digunakan sebagai kondar, hanya saja, papar Biran, harus
diperhatikan penggunaannya. Konsultasi dengan dokter sangat disarankan. ''Kondar ini
termasuk cara yang lebih mahal dari alkon biasa. Karena itu, penggunaannya dipertimbangkan
Kondar tembaga, misalnya, dipasang sampai tujuh hari setelah senggama. Namun, untuk jenis
lainnya diminum paling lama tiga hari setelah hubungan seksual. ''Semakin lama memakai atau
meminum kondar dari waktu bersenggama, semakin besar risiko terjadi kehamilan. Kondar
menjadi tak efektif bila lewat dari waktu tadi,'' ujar Biran.
Kondar aman digunakan oleh hampir semua wanita, namun tak boleh dipakai bila terjadi
kehamilan yang sudah pasti. Tak ada efek samping serius dari penggunaan kondar, kecuali mual
dan muntah. Karena itu, Biran menyarankan agar mengonsumsi pil antimual dan antimuntah 1-2
jam sebelum minum kondar.
Menurut Ketua Umum PP Fatayat NU, Dra Maria Ulfah Anshor, mencegah terjadinya kehamilan
jauh lebih baik (maslahat) daripada menggugurkan kandungan. ''Ini penting karena di
masyarakat kita, pertolongan biasanya terlambat,'' ujarnya.
Ia mengungkapkan, dalam Alquran maupun hadis tak bercerita secara eksplisit soal kondar
kecuali mengenai senggama terputus (coitus interuptus atau 'azl). Dalam Alquran Surat An Nisa
(4-9), Al Baqarah (2:185), dan Al Hajj (22:78) dituliskan bahwa sebaiknya takut kepada Allah
orang-orang yang meninggalkan anak-anak yang lemah dan Allah menghendaki kemudahan
Di samping itu, beberapa ulama fikih sepakat bahwa 'azl dibolehkan dalam Islam (mubah), tapi
ada pula yang menganggapnya tak patut (makruh). Anggapan tak patut karena perbuatan
tersebut menghapuskan hak perempuan untuk merasakan kepuasan seksual dan memiliki anak.
Makanya, 'azl dilakukan seizin perempuan bersangkutan.
''Berdasarkan analogi terhadap hukum 'azl, maka penggunaan alkon dan kondar diperbolehkan
sepanjang tak menimbulkan bahaya bagi perempuan dan pasangannya,'' ujar Maria.
Menanggapi penggunaan kondar yang diselewengkan dalam kegiatan perzinahan, Maria
menyatakan agar menilainya dari sisi kepentingannya. Zinah, katanya, jelas diharamkan agama.
''Persoalannya, bukan kondarnya yang haram, namun zinahnya. Kita harus melihat konteksnya.
Kalau di sisi HAM, pelanggaran HAM seperti perkosaan, jelas kondar dibutuhkan.''
Berdasarkan saran dari Badan Koordinasi Keluarga Berencana Nasional (BKKBN) dan para
pakar kedokteran, ada beberapa alat kontrasepsi (alkon) yang sering digunakan antara lain:
1. Pil KB Kombinasi dan pil progestin (mini pil).
Jenis pil ini diminum setiap hari. Bila berhenti diminum, maka kehamilan bisa terjadi. Mini pil
efektif bagi ibu menyusui. Kedua pil ini memiliki efek samping, meski gejalanya tak berbahaya.
Pil kombinasi mencegah penyakit kanker tertentu, anemia zat besi, dan nyeri haid.
2. Suntik KB
Alkon ini disuntikkan setiap satu atau tiga bulan. Bila berhenti memakai alkon ini, kehamilan
dapat terjadi. Aman bagi ibu menyusui. Efek sampingnya adalah gangguan perdarahan, sakit
kepala, dan kenaikan berat badan. Jenis ini bermanfaat mencegah tumor rahim dan kehamilan di
3. Susuk KB
Ini alkon dalam bentuk batangan berjumlah 1, 2, atau 6 buah yang bisa dimasukkan di bawah
kulit pada lengan bagian atas. Bila diangkat susuknya, kehamilan bisa terjadi. Aman bagi ibu
menyusui. Efek sampingnya adalah perubahan pola haid, tidak haid, dan vlek. Susuk KB
bermanfaat untuk mencegah anemia dan kehamilan di luar kandungan.
4. Metode operasi (wanita-tubektomi, pria-vasektomi)
Ini KB permanen bagi mereka yang memutuskan tak memiliki anak lagi. Operasinya aman dan
sederhana dengan bius lokal. Tak ada efek samping jangka panjang. Tak berpengaruh terhadap
kemampuan atau kepuasan seksual. Hanya saja, pada vasektomi baru efektif setelah tiga bulan
pascaoperasi. Jadi, sebelum itu masih perlu penggunaan kondom.
Jenis ini paling efektif untuk mencegah kehamilan, sekaligus melindungi infeksi penyakit
menular dan HIV/AIDS.
6. Alkon dalam rahim (IUD)
Alatnya dari plastik lentur yang dimasukkan ke dalam rongga rahim. Dipasang oleh tenaga
medis. Bila berhenti, kehamilan bisa terjadi. Ini adalah KB jangka panjang. Efeknya berupa masa
haid lebih panjang, tak nyaman, infeksi panggul, dan IUD bisa keluar bila mengejan. Tak
disarankan bagi mereka yang mengidap penyakit menular seksual.
7. Metode vaginal
Bentuknya tisu KB, diagfragma, dan kap yang dipakai sendiri. Alkon ini dimasukkan ke dalam
vagina setiap kali sebelum berhubungan. Bermanfaat mencegah infeksi penyakit menular
seksual, namun cenderung terkena infeksi saluran kencing.
8. Sistem kalender
Caranya dengan menghitung masa subur dalam siklus haid. Pada masa subur wanita tak
berhubungan badan, atau bisa saja dilakukan asalkan menggunakan kondom atau metode
vaginal. Tak ada efek samping fisik. Dianjurkan bila cara KB lain sulit digunakan pada saat
demam, infeksi vagina, setelah melahirkan, atau pada waktu menyusui.
9. Metode pemberian ASI (lactational amenorrhoe method)
Menyusui bayi ekslusif (0-6 bulan tanpa makanan pendamping ASI atau tambahan) bisa menjadi
alkon. Syaratnya, ibu menyusui secara penuh siang-malam, belum dapat haid, dan bayinya
belum berumur enam bulan. Selepas itu, sang ibu dianjurkan mempertimbangkan penggunaan
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Summary of Program Report
Emergency Contraception Pill Socialization
No. Name of District Medical
Activity Midwife Dinkes Other Total
I. Central Java Province
1 Kota Semarang 27-Apr-05 29 41 70
2 Kabupaten Pati 27-Apr-05 70 70
3 Demak 28-Apr-05 20 40 10 70
4 Magelang 28-Apr-05 17 53 70
5 Sragen 29-Apr-05 34 32 4 70
6 Kudus 02-May-05 16 50 2 2 70
7 Tegal 02-May-05 10 60 70
8 Pekalongan 03-May-05 17 53 70
9 Blora 03-May-05 70 70
10 Wonosobo 04-May-05 12 54 2 2 70
11 Batang 04-May-05 20 50 70
12 Surakarta 04-May-05 24 41 5 70
13 Sukoharjo 07-May-05 14 56 70
14 Kab. Semarang 07-May-05 23 35 12 70
15 Boyolali 09-May-05 24 42 4 70
16 Karanganyar 09-May-05 17 39 10 4 70
17 Tegal 11-May-05 26 33 7 4 70
II. Nusa Tenggara Barat (NTB)
18 Lombok Barat 04-May-05 22 48 5 75
19 Sumbawa 09-May-05 15 30 11 14 70
20 Kota Mataram 03-May-05 13 47 10 5 75
21 Badung 20-Apr-05 11 55 2 2 70
22 Tabanan 21-Apr-05 20 40 4 6 70
23 Klungkung 26-Apr-05 8 59 3 70
24 Bangli 27-Apr-05 10 60 70
25 Karangasem 28-Apr-05 11 56 3 70
26 Gianyar 02-May-05 11 59 70
27 Buleleng 03-May-05 13 52 5 70
28 Jembrana 04-May-05 6 63 1 70
IV. DKI Jakarta
29 Jakarta Pusat 13-Apr-05 51 1 52
30 Jakarta Utara 14-Apr-05 50 50
31 Jakarta Barat 15-Apr-05 34 5 39
32 Jakarta Selatan 18-Apr-05 73 73
Summary of Program Report
Emergency Contraception Pill Socialization
No. Name of District Medical
Activity Midwife Dinkes Other Total
33 Jakarta Timur 19-Apr-05 38 38
34 Serang 14-Apr-05 14 56 70
35 Lebak 20-Apr-05 63 7 70
36 Kota Cilegon 26-Apr-05 8 62 70
37 Kota Tangerang 03-May-05 65 5 70
38 Tangerang 28-Apr-05 70 70
39 Pandeglang 04-May-05 70 70
40 Gunung Kidul 14-Apr-05 18 38 14 70
41 Bantul 19-Apr-05 22 40 8 70
42 Sleman 20-Apr-05 15 49 2 4 70
43 Kulon Progo 11-Apr-05 7 40 10 13 70
44 Kota Jogyakarta 12-Apr-05 12 45 7 6 70
VII North Sumatra
45 Deli Serdang 30-Apr-05 11 59 70
46 Tapanuli Utara 06-May-05 9 55 6 70
47 Tanjung Balai 07-May-05 7 63 1 71
48 Binjai 12-May-05 16 50 4 70
49 Langkat 29-Apr-05 14 56 70
50 Labuhan Batu 11-May-05 6 60 4 70
51 Karo 15-Apr-05 12 51 7 70
52 Pematang Siantar 16-Apr-05 7 59 4 70
53 Sibolga 13-May-05 4 53 3 10 70
VIII Nusa Tenggara Timur (NTT) 0
54 Timor Timur Selatan 28-May-05 8 22 25 15 70
55 Timor Timur Utara 26-May-05 5 28 29 8 70
56 Belu 23-May-05 16 30 15 9 70
IX East Java 0
57 Kota Surabaya 03-Jun-05 52 17 1 70
58 Kab. Sidoarjo 23-Jun-05 34 21 15 70
59 Kab. Malang 19-May-05 38 38 76
60 Kota Malang 17-May-05 11 42 5 5 63
61 Kab. Pasuruan 26-Apr-05 19 43 8 70
Summary of Program Report
Emergency Contraception Pill Socialization
No. Name of District Medical
Activity Midwife Dinkes Other Total
62 Kota Pasuruan 11-May-05 23 47 70
63 Kab. Jombang 26-Apr-05 22 73 5 100
64 Kab. Mojokerto 03-May-05 30 33 7 70
65 Kab. Nganjuk 20-Jun-05 19 50 1 70
66 Kab. Madiun 25-May-05 17 30 1 22 70
67 Kab. Ponorogo 25-May-05 42 16 12 1 71
68 Kab. Gresik 07-Jun-05 16 46 2 6 70
69 Kab. Bojonegoro 19-May-05 29 23 16 2 70
70 Kab. Jember 16-May-05 53 15 2 70
71 Kab. Bondowoso 10-May-05 15 50 7 3 75
72 Kab. Blitar 12-May-05 25 25 13 7 70
73 Keb. Kediri 18-May-05 15 53 2 70
X NORTH SULAWESI
74 Kab. Minahasa Utara April 14,2005 8 43 18 1 70
75 Kab. Tomohon April 21,05 3 67 70
76 Kab. Minahasa April 28,05 9 49 12 70
XI SOUTH SUMATERA 0
77 Ogan Komering Ilir April 7,05 11 57 2 70
78 Banyuasin April 14,05 10 60 70
79 Musi Banyuasin May 17,05 5 63 2 70
80 Palembang July 9,05 21 43 12 1 77
81 Prabumulih May 10,05 2 64 4 70
82 Ogan Ilir April 19,05 7 60 3 70
XII SOUTH SULAWESI 0
83 Pangkep April 6,05 70 70
84 Takalar April 19,05 61 9 70
85 Gowa April 27,05 11 53 6 70
86 Jeneponto April 19,05 11 59 70
87 Maros April 19,05 12 46 8 4 70
88 Bantaeng May 17,05 5 50 13 2 70
89 Barru May 20,05 4 47 10 9 70
90 Pare-Pare May 21,05 10 55 4 1 70
91 Sidrap May 27,05 7 59 4 70
92 Pinrang May 28,05 12 53 5 70
XIII WEST JAVA 0
Summary of Program Report
Emergency Contraception Pill Socialization
No. Name of District Medical
Activity Midwife Dinkes Other Total
93 Purwakarta June15,05 57 6 7 70
94 Cirebon June 14,05 21 21 5 25 72
95 Subang June9,05 10 49 11 70
96 Sumedang June22,05 26 41 3 70
97 Majalengka June 13,05 10 50 10 70
98 Garut June 7,05 17 41 6 6 70
99 Sukabumi June 23,05 12 45 4 9 70
100 Karawang June 20,05 31 25 11 67
101 Indramayu June 14,05 7 63 70
102 Kuningan June 30,05 6 64 70
103 Bogor June 21,05 19 48 3 70
104 Kota Bandung June 30,05 25 26 10 9 70
Jogyakarta 01-May-05 48 48
II PW Muslimat NU 17-May-05
Jatim 50 50
III. IBI PUSAT 04-May-05 0 47 0 0 47
1,359 5,225 519 276 7,379
ECP Card by PT. Tunggal
ECP Poster by PT. Tunggal
Distribution List of OBSI Pocket Guide
No. Name/Organization Quantity
1. Bidan Delima Program 10,000
2. Muslimat 2,000
3. Fatayat NU 1,000
4. Muhammadiyah 6,000
5. PT. Tunggal 5,000
6. PATH 100
7. STARH Districts 16,000
8. HSP 5,000
9. DKT 1,000
10. Save the Children 100
11. UNFPA 50
12. YKB 100
13. PKBI 200
14. BKKBN 20,000
15. DepKes 22,000
16. Catalyst 200
17. White Ribbon 200
18. CCP Baltimore 50
19. IYP members 1,000
20 CARE 50
21. ASA 50
22. IBI 50
23. Urban Nutrition Project 50
24. AusAID NTB & NTT 200
24. JHU Library Indonesia 200