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SAMPLE REGISTRATION SYSTEM
2014
CENTER FOR COMMUNITY EMPOWERMENT, HEALTH POLICY AND HUMANITIES
NATIONAL INSTITUTE OF HEALTH RESEARCH & DEVELOPMENT
MINISTRY OF HEALTH REPUBLIC OF INDONESIA
2015
INDONESIA
Indonesian SRS 2014 ii
NIHRD Library Cataloguing in Publication Data
Indonesia: Sample Registration System 2014
1. Indonesia 2. Health outcome indicators 3. Millennium Development Goals
4. Causes of death
The National Institute of Health Research and Development 2015
29 Jalan Percetakan Negara
Jakarta 10560
INDONESIA
Internet: www.Litbang.kemkes.go.id
E-mail: sesban@litbang.kemkes.go.id
All rights reserved
ISBN
MINISTER OF HEALTHREPUBLIC OF INDONESIA
FOREWORD
Millennium Development Goals with health related goals (no. 4,5and 6) will end in 2015. All countries, including lndonesia, whichsigned the MDGs in 2000 have to report their achievements.
ln order to obtain outcome indicators and causes of death, theNational lnstitute of Health Research and Development - Ministryof Health Republic of lndonesia in collaboration with theDirectorate General of Population and Civil Registry - Ministry ofHome Affairs and local governments in 30 provinces, 119
districts and cities that represent lndonesia, has initiated Sample RegistrationSystem that collected mortality data from the households with death events fromJanuary to December 2014.
The results show the "real-time" health outcome indicators representative forlndonesia and describe the achievements of MDG 4, 5 and 6 in2AM.Besides, the results will guide the public awareness on the selection of priority healthprograms and provide input for appropriate allocation of health resources in thehealth sector, as well as accelerate the efforts to achieve the national healthdevelopment objectives.
On this occasion, I would like to congratulate and express my highest appreciation tolocal government officials (province, district, city, subdistrict, village), NIHRD
researchers, officials from provincial, district and city Health Offices; physicians and
paramedics of community health center (PUSKESMAS) as well as all parties
involved in this activity.
Hopefully, the findings will contribute to national efforts in improving the health and
welfare of the lndonesian people.
tu,Prof. Dr. dr. Nila Farid Moeloek, Sp. M(K)
Minister of Health of the Republic of lndonesia
tndonesian sRS 2orn E
H.R. Rasuna Said Street Block X5, Kav. 4-9 Jakarta 12950 PhonelFax (+6221) 5201591
Indonesian SRS 2014 iv
PREFACE
Real-Time Health Outcome Indicators to evaluate national achievement of Millennium
Development Goals 4, 5 and 6 are needed to be used as milestones for National Health
Development Programs.
In order to assess accurately, the Center for Community Empowerment, Health Policy and
Humanities – the National Institute of Health Research and Development, Ministry of Health
Republic of Indonesia has implemented the 2014 Sample Registration System with the objective
of collecting births, deaths and causes of death in the sample area that includes 128
subdistricts, 119 districts and cities; located in 30 provinces in all over Indonesia.
This report presents results of the 2014 Sample Registration System and the key findings as well
as the policy implications.
The findings consist of health outcome indicators for 2014 (real time, with adjustment) and
Underlying Causes of Mortality based on International Statistical Classification of Diseases and
Related Health Problems, Tenth Revision, World Health Organization (1992); using life cycle
approach as stated in the Indonesian Medium Term Health Development Plan 2015 - 2019
Hopefully this activity will contribute to the sustainable efforts to improve health programs in
Indonesia and in designing more effective interventions to control priority diseases.
Soewarta Kosen
Principal Investigator and Editor
Indonesian SRS 2014 v
ACKNOWLEDGEMENTS
The 2014 Indonesian Sample Registration System was successfully completed due to the efforts
and involvement of various public institutions and community organizations at various levels
and at different stages of the activities.
Herewith, we would like to thank everyone who helped making the efforts a success. First of all,
we are grateful to the Ministry of Home Affairs and local governments in all over Indonesia, for
its leadership and continuous support. We would also like to express our thanks to the Badan
Pusat Statistik (BPS)/Statistics Indonesia for providing guidance and support in the sample
design and selection of samples (subdistricts), using 2008 Village Potency Survey data.
At the NIHRD, we express our gratitude to Prof. Tjandra Yoga Aditama, M.D., (Pulmonologist).,
MARS., DTM&H, DTCE., the Head of the National Institute of Health Research & Development
and to all Researchers under the leadership of . Soewarta Kosen, who coordinated the tasks
related to SRS, preparation, planning, implementation, data analysis and report writing.
We would also like to express our thanks to the Ministry of Home Affairs and Provincial, City
and District Governments in the sample area for their administrative support and collaboration.
We are also sincerely grateful to the GLOBAL FUND – Cross Cutting Health Systems
Strengthening Intervention 2012 – 2014, for their administrative support and financial
assistance in conducting the Indonesian SRS.
This acknowledgement would not be complete without expressing appreciation for the hard
work showed by the interviewers, supervisors, and IT personnel involved in collecting and
processing the SRS; as well as by the administrative staff at the NIHRD. Finally, we appreciate
the informants and family members of the decease who were willingly respond to the detailed
questions with patience and without any expectation.
Indonesian SRS 2014 vi
Agus Suprapto, DDS., M.Kes.
Director, Center for Community Empowerment, Health Policy and Humanities
National Institute of Health Research & Development
Ministry of Health Republic of Indonesia
Indonesian SRS 2014 vii
CONTRIBUTORS
Soewarta Kosen
Ingan Ukur Tarigan
Tita Rosita
Endang Indriasih
Yuslely Usman
Tati Suryati
Endah Dwi Pratiwi
Retno Widyastuti
Idawati Muas
Merry Lusiana
Pramita Andarwati
Tety Rachmawati
Tri Juni Angkasawati
Riswati
Ni’matun Nurlaela
Meda Permana
Irfan Ardani
Indah Pawitaningtyas
Ria Yudha Permata
Linda Nilawati
Tuty Alawijah
Sugito Ariyana
Firda Oktaviani
Risna
Indonesian SRS 2014 viii
CONTENTS
Contents Page
Foreword…………………………………………………………………………………………………………...
iii
Preface……………………………………………………………………………………………………………...
iv
Acknowledgements………………………………………………………………………………………..….
v
Contributors………………………………………………………………………………………………………
vii
Contents……………………………………………………………………………………………………………
viii
List of Tables……………………………………………………………………………………………………..
x
List of Figures…………………………………………………………………………………………………….
xii
Executive Summary…………………………………………………………………………………………… Xiii
1 Background……………………………………………………………………………………… 1
2 Objectives……………………………………………………………………………………….. 4
2.1 Specific Objectives……………………………………………………………………………. 4
3 Strategies…………………………………………………………………………………………. 5
3.1 Strategies that were applied include………………………………………………… 5
3.2 Verification of Completeness were carried out using several methods……………………………………………………………………………………………
5
4 Methods…………………………………………………………………………………………. 6
4.1 Selection of National Representative SRS Sites…………………………………. 6
4.2 Report Mechanism of Death Event…………………………………………………. 8
4.3 Organization of SRS…………………………………………………………………………. 8
5 Results……………………………………………………………………………………………. 9
Indonesian SRS 2014 ix
5.1 Health Outcome Indicators……………………………………………………………... 10
6 Conclusions………………………………..…………………………………………………… 34
References……………………………………………………………………………………………………….. 38
Annex 1……………………………………………………………………………………………………………. 39
Annex 2……………………………………………………………………………………………………………. 44
Annex 3…………………………………………………………………………………………………………… 45
Annex 4…………………………………………………………………………………………………………… 61
Indonesian SRS 2014 x
LIST OF TABLES
Table No. Table Name Page No.
Table 4.1 Total Population, total number of subdistrict, and average number of population in subdistrict by District and City, Population Census 2010 and Village Potency Survey 2008
7
Table 5.1 Health Outcome Indicators (With Adjustment), Indonesia 2014
10
Table 5.2 Progress of Health Outcome Indicators (MDGs: 1991 & 2015); DHS 2012 & SRS 2014
11
Table 5.3 Distribution of Proportion of Deaths by Sex and Age Group, Indonesian SRS 2014
12
Table 5.4 Twenty Leading Underlying Causes of Death (Males & Females), Indonesian SRS, 2014
14
Table 5.5 Twenty Leading Underlying Causes of Death among Males Indonesian SRS, 2014
15
Table 5.6 Twenty Leading Underlying Causes of Death among Females, Indonesian SRS, 2014
16
Table 5.7 Distribution of Maternal Mortality By Cause, Indonesian SRS, 2014
18
Table 5.8 Leading Underlying Causes of Death among Neonatal, Indonesian SRS, 2014
19
Table 5.9 Leading Underlying Causes of Death among Neonatal, Indonesian SRS, 2014
20
Table 5.10 Leading Underlying Causes of Death among Late Neonatal (8-28 days), Indonesian SRS, 2014
21
Table 5.11 Leading Underlying Causes of Death among Infants, Indonesian SRS, 2014
22
Indonesian SRS 2014 xi
Table 5.12 Leading Underlying Causes of Death among Children Aged 1-4 Years, Indonesian SRS, 2014
23
Table 5.13 Leading Underlying Causes of Death among Children Underfives (aged 0-59 months), Indonesian SRS, 2014
24
Table 5.14 Leading Underlying Causes of Death among Children Aged 5-14 Years, Indonesian SRS, 2014
25
Table 5.15 Leading Underlying Causes of Death among Population Aged 15-44 Years, Indonesian SRS, 2014
26
Table 5.16 Leading underlying causes of death among Population Aged 45-59 years, Indonesian SRS, 2014
27
Table 5.17 Leading underlying causes of death among the elderly aged 60 + years, Indonesian SRS, 2014
28
Table 5.18 Distribution of Injury Mortality by External Causes, Indonesian SRS, 2014
31
Table 5.19 Distribution of Injury Mortality by Type of Transport, Indonesian SRS, 2014
32
Table 5.20 Proportion of Deaths due to HIV/AIDS, Tuberculosis and Malaria from Total Deaths, Indonesian SRS, 2014
33
Indonesian SRS 2014 xii
FIGURES
Figure No. Figure Name Page No.
Figure 1.1 Stages of Vital Registration
3
Figure 4.1 Map of SRS Region, 2014
7
Figure 5.1 Distribution of Proportion of Deaths by Sex and Age Group, Indonesian SRS 2014
13
Figure 5.2 Distribution of Deaths by Place of Event, Indonesian SRS, 2014
13
Figure 5.3 Distribution of Maternal Mortality into proportion (%) of Direct and Indirect Obstetric of Obstetric Deaths, Indonesian SRS, 2014
17
Figure 5.4 Distribution of Maternal Deaths by Place of Death, Indonesian SRS, 2014
18
Figure 5.5 Proportion of Neonatal Deaths by Place of Death, Indonesian SRS 2014
22
Figure 5.6 Distribution of Mortality due to Cerebrovascular Diseases (Stroke) by Age Group, Indonesian SRS, 2014
29
Figure 5.7 Distribution of Mortality due to Ischaemic Heart Disease by Age Group, Indonesian SRS, 2014
30
Figure 5.8 Distribution of Mortality due to Transport Accidents by Age Group, Indonesian SRS, 2014
31
Indonesian SRS 2014 xiii
EXECUTIVE SUMMARY
Accurate basic demographic statistics (births, deaths, marriage, migration) are basis for
formulation of health policies and management of effective government. Mortality statistics,
death certificate as well as medical certificate of multiple causes of death from hospitals are
incomplete, due to the limited utilization of the hospitalization services.The benefits of a well-
developed information system include the ability to monitor impact of health programs, better
quality information, and enable more efficient delivery of health care services.
The Objectives of the SAMPLE REGISTRATION SYSTEM (SRS) were to generate reliable estimates
of national outcome indicators and multiple causes of deaths (in accordance with ICD-10) that
include Cause Specific Mortality Rate of major diseases annually (within the framework of Law
No. 23/2006 and Law No. 24/2013 on Population Administration), as well as to obtain
representative national outcome indicators (Maternal Mortality Ratio/MMR, Neonatal
Mortality Rate/NMR, Infant Mortality Rate/IMR, Under fives mortality rate) and fulfilling the
need to monitor achievements of MDGs 4, 5 and 6.
All data in SRS (including the death events at hospital) were collected by trained paramedical
personnel through household visits, using WHO Standard Verbal Autopsy instruments (paper &
pencil) and the diagnosis verified by trained physicians. The main components of SRS, include
continuous (longitudinal) enumeration of vital events, an independent survey for recording
births and deaths, matching of events recorded during continuous enumeration and those
listed in survey (capture and recapture) and field verification of unmatched and partially
matched events.
Indonesian SRS 2014 xiv
Selection of National Representative of SRS Sites was conducted using Village Potency Survey
(PODES) data; a total of 128 sites in 119 districts or cities in 30 provinces was selected.
Indonesian SRS sites cover 128 subdistricts in 119 Districts and cities, located in 30 provinces
with total population covered about 3.5 % of total Population, that is about 8.8 millions.
Collected live births data in 128 SRS sites, adjusted by projection of 2010 Population Census for
2014 and updated Population Administration data from Ministry of Home Affairs was used as
denominator.
Standard Verbal Autopsy instruments were used for interviews with family members and/or
caregivers. ICD-10 rules and coding system were applied to the results of verbal autopsy
interviews. Respondents were primary care-giver (usually family member) who were with the
deceased prior to death event, Verbal autopsy instruments consist of 3 types, that is Instrument
for neonatal cases (aged less than 4 weeks), Instrument for Infant and child cases (aged 4 weeks
to 14 years) and Instrument for adult cases (aged 15 years and over)
RESULTS. Total population observed was 8.898.429 and total death cases found from
January 1, 2014 to December 31, 2014 were 41,590; that consisted of 927 Neonates ( 0-28
days), 1,065 aged 29 days-14 years and 39,598 aged 15 years and above. The crude coverage
was 73.0 % by applying CDR used to set target (National Projection for 2014) of 6.4 per 1,000
population
POLICY IMPLICATIONS. Indonesia needs to enhance the efforts to improve the population
health status. To accelerate reduction of the Burden of Non Communicable Diseases and
Injuries, special efforts should be prioritized, planned and implemented; such as Control of
major risk factors of Non-Communicable Diseases (unhealthy diet including reduction of salt
consumption and avoiding high total cholesterol food, controlling high blood pressure and
smoking behavior). Special preventive efforts by the health sector and other related sectors
should be carried out to control road traffic injuries and other unnatural deaths.
Indonesian SRS 2014 xv
Despite sustained and rapid reduction in child mortality, a substantial fraction of the burden of
disease was due to premature mortality in children. Neonatal causes, diarrhea and pneumonia
were the major causes. There are need to introduce low cost & simple resuscitation kit for
asphyxiated baby in standard midwifery kit, incorporating PCV-13 and Rotavirus Vaccines in
routine immunization program, revitalization of community knowledge & practices on diarrhea
management and use of ORT.
There are also urgent need to improve the quality and quantity of maternity and neonatal care
through Basic and Comprehensive Emergency Maternal and Neonatal Care (PONED & PONEK)
facilities as well as the referral system; that require improved, integrated and comprehensive
efforts.
Stroke was not only the top leading cause of mortality (21.1 % of total); it is also the disease
with the biggest gap between Indonesia and comparator countries. Key factors include high
level of hypertension, high tobacco consumption, poor diet especially high sodium and glucose
consumption and low fruit consumption, lack of physical activity as well as the inadequate
management of Diabetes Mellitus. Two key strategies to curb high stroke rates include risk
factor reduction through public health campaign, taxation and legislation, and blood pressure
management through effective diagnosis, treatment and follow up in primary care facilities.
Tuberculosis was the fourth leading cause of mortality, with 5.7 % from total cases. Results of
2013-2014 TB Prevalence Survey showed the prevalence of 759 per 100,000 population,
significantly increased (more than doubled) compared with previous findings. Case detection
rates need to be increased through better diagnostic capabilities in the peripheral health
system facilities (chest X-Ray, bacteriological culture, training of personnel).
Road traffic injuries (dominated by motor-cycles) are the main cause of injury burden and
maintained steadily. At present, it causes annual deaths about 26,000 and has the potential for
burden reduction. Successful multi-sector approaches to reduce road traffic injuries are
Indonesian SRS 2014 xvi
needed, including road safety engineering, traffic calming, separation of pedestrians from
traffic, seat-belt & helmet law enforcement, and enforcement of vehicle safety standards.
Incidence of Diabetes Mellitus and Chronic Kidney Diseases have increased by 86% and 90%
respectively in the last 25 years. Indonesia needs to enhance the management of
complications, such as retinopathy, nephropathy, neuropathy and cardiovascular
complications, through improved primary care programs
SRS found that tobacco related diseases were still high in Indonesia. About 36.3 % of population
and 65 % among males alone were active smokers (Riskesdas 2013). Rising burden in men
means that tobacco’s toll in Indonesia is nearly equal to the developed countries situation in
1990. Intensified tobacco control efforts following the MPOWER/ WHO Policy package and
FCTC are urgently needed.
Finally, incorporating all sources of Vital Registry, namely hospital data (multiple causes of
death based on ICD-10), community based mortality data (Verbal Autopsy) and unnatural death
data from Local Police and Forensic Department of Hospitals should be accelerated under the
umbrella of Civil Registration and Vital Statistics (CRVS).
Indonesian SRS 2014 1
1. BACKGROUND
Accurate basic demographic statistics (births, deaths, marriage, migration) are fundamental
evidence fundamental evidence for the formulation of health policies and management of
effective government. In Indonesia at present, mortality statistics, death certificates as well
as medical certificate of cause of death from hospitals are incomplete, due to the limited
utilization of hospital services. Baseline Health Research 2013 found that only 2.3 % of the
Indonesian people use hospital in-patient services and only 10.4 % use out-patient services
in one year.
Sources of Health Information System and basic demographic statistics in Indonesia include:
Population Administration Information System (SIAK), Population Census, National
Socioeconomic Survey, Demographic Health Survey, National Health Survey, Baseline Health
Research (RisKesDas), regular recording-reporting system of Puskesmas (Community Health
Center) and Hospitals, surveillance data (nutrition, Maternal & Child Health including results
of Audit Maternal Perinatal), sentinel data for mortality (IMRSSP), Family Planning reporting
system, and others.
In the past, the mortality registration system in Indonesia has not provided the needed
information on number and causes of death at national and local (provincial, district & city)
levels due to severe under reporting.
For more than two decades, the Ministry of Health has used results of community based
mortality surveys using verbal autopsy instruments, to obtain multiple causes of death
(underlying, antecedent and direct cause) and to determine mortality levels that were
severely under reported (about thirty five percent).
Calculating outcome indicators (Infant Mortality Rate, Under Five Mortality Rate, Maternal
Mortality Rate, etc.) using indirect methods or survey data will only describe the situation
about four to five years before the survey was conducted. This makes it difficult to monitor
achievements of MDGs 4,5,6; construct life tables or calculate various outcome indicators in
real-time (current).
Indonesian SRS 2014 2
The benefits of a well-developed vital registration system include the ability to monitor the
impact of health programs, better quality information, and more efficient delivery of health
care services. With sound data sources and proper data collection, data and evidence can
be transformed into policy using best practices.
With the need to monitor and evaluate Millennium Development Goals especially MDGs 4
(infant & child mortality), 5 (maternal mortality) and 6 (deaths due to HIV/AIDS, Malaria and
Tuberculosis), the Center for Community Empowerment, Health Policy and Humanities -
National Institute of Health Research and Development, Ministry of Health has initiated a
nationally representative Sample Registration System (SRS) that consolidates mechanisms
for collection, analysis and calculation of mortality statistics within the broader process of
civil registration in Indonesia, towards generating reliable estimates of national
representative outcome indicators (Crude Birth Rate, Total Fertility Rate, Crude Death Rate,
Infant Mortality Rate, Maternal Mortality Rate, etc.) and multiple causes of death annually.
The main components of the Indonesian Sample Registration System (SRS) include, among
others:
a. Optimization of the 2010 Population Census and its projection for 2014, as the base-
line population.
b. Continuous (longitudinal) enumeration of vital events based on Population
Administration Law
c. An independent half-yearly survey for recording and verification of births and deaths
d. Matching of events recorded during continuous enumeration and those listed in the
survey;
e. Field verification of unmatched and partially matched events
f. Provision of SRS sites as field laboratories for piloting and evaluation of various public
health interventions
The Indonesian SRS can be considered an intermediate objective, before achieving an
established and complete vital registration system all over the country (Figure 1), as
envisaged in the 2006 and 2013 Population Administration Law.
Indonesian SRS 2014 4
2. OBJECTIVES
The General Objective in developing the Indonesian SRS is to generate reliable
representative estimates of national outcome indicators (Crude Birth Rate, Crude Death
Rate, Neonatal Mortality Rate, Infant Mortality Rate, Under five Mortality Rate, Maternal
Mortality Rate, etc.) and multiple causes of deaths based on WHO ICD – 10 (International
Statistical Classification of Diseases and Related Health Problems, Tenth Revision, 1992) for
2014.
2.1. Specific Objectives
a. Specific objectives of the SRS are as follows:To obtain representative national
outcome indicators (also fulfiling the need for monitoring MDGs 4, 5): Crude
Death Rate, Crude Birth Rate, Total Fertility Rate, Infant Mortality Rate,
Neonatal Mortality Rate, Under Five Mortality Rate, Maternal Mortality Ratio;
for 2014
b. To obtain multiple causes of death based on ICD – 10 (MDG 6)
c. To use SRS findings for policy formulation
Indonesian SRS 2014 5
3. STRATEGIES
3.1. Strategies applied Strategies applied in developing the SRS include:
a. Close collaboration with local government officials at the grass-roots level
(City/District and below) and assignment of the City or District Health Officer
as the responsible officials and Subdistrict Health Center (Puskesmas) as the
responsible health institutions
b. Applying the IMRSSP (Indonesia Mortality Registration System Strengthening
Project) methods and procedures as well as training modules and data
collection framework in SRS areas.
c. Collection of all mortality cases in SRS areas and using Verbal Autopsy
instruments, based on “Verbal Autopsy Standards: ascertaining and
attributing cause of death”, WHO 2007.
d. Applying ICD-10 multiple causes of death and its coding system
e. Establish networking with local subdistrict and village public officials
f. Capacity development of local Puskesmas personnel, to assure completeness
and high quality of data
g. Enforcement of existing Population Administration Laws (Law No. 23/2006 and
Law No. 24/2013) that cover registration of vital events
3.2. Verification of completeness methods:
1. Capture-Recapture Method to assess completeness of registration
2. Validity assessment of reported multiple causes of death data
3. Continuous local data collection over time
4. Uses of cohort data of pregnant mothers and neonates (MCH Handbook/Buku KIA)
5. Regular coordination between population administration officials and health
personnel at village and sub district level
Indonesian SRS 2014 6
4. METHODS
4.1. Selection of Nationally Representative SRS Sites Indonesia is divided into Cities (representing urban areas) and Districts (representing rural
areas). Using Village Potency Survey (PODES) 2008 data, a total number of subdistricts in
Cities and Districts were identified. Indonesia is stratified into Cities (represent urban) and
Districts (represent rural) using Village Potency Survey 2008 data.
The estimated total population sample needed for SRS was a minimum of 2 % of the total
population (Projected from Population Census 2000: 231,114,483), that is 4,622,290. To
achieve this sample size a total of 25 subdistricts in cities and 103 subdistricts in Districts in
Indonesia were systematically selected as SRS Areas. The average total sub-district
population is 36,033 and the total selected SRS Sites are at least 128 (ANNEX 1)
Subdistricts were selected as the administrative level for SRS Sites, as they are the lowest
administrative Unit with a defined border in a city or district that includes one or more
Community Health Centers (Puskesmas).
Indonesian SRS 2014 7
Figure 4.1 : Map of SRS Region, 2014 Table 4.1: Total Population, total number of subdistrict, and average number of population in subdistrict by District and City, Population Census 2010 and Village Potency Survey 2008
Area Total no. of populationa
Estimated total no. of population that should be covereda
Total No. of Subdistrictb
Total No. of SRS sites
District 185,983,496 3,830,488 5,767 103
City 46,475,560 929,512 647 25
Total 231,114,483 4,622,290 6,414 128
a Projected Population in 2010 (based on Population Census 2000)
b Village Potency Survey 2008
All data in SRS (including the death events at hospital) were collected by trained paramedical personnel through household visits, using Verbal Autopsy instruments (paper & pencil) and the diagnosis verified by trained physicians
The Joint Decree of the Minister of Home Affairs and the Minister of Health (January 2010)
on Reporting of Death and Cause of Death facilitated the recording of events and
cooperation between the two sectors at the grass-roots level
Indonesian SRS 2014 8
4.2. Report Mechanism of Death Event
Information on any deaths taking place at home are obtained by the subdistrict health
center through village administrators and health cadres. The trained health center personnel
then visit the house of the deceased and ascertain the history of illness and treatment from
the family using a semi-structured verbal autopsy instrument. Then, the health center
physician will assign the cause of death and the trained coders will provide ICD-10 codes.
For deaths occurring in health facilities (especially hospital), a medical certificate with
multiple causes of death is completed by the attending physician. Completeness of death
registration is asessed by triangulating data from different sources.
Standard instruments are used for interviews with family members and/or caregivers with
the following characteristics:
Respondent should be a primary caregiver (usually family member) who was with the
deceased prior to the death event
Preferably short recall periods are attained (< 3 months)
Adaptation of instruments to the local situation
Verbal autopsy instruments consist of 3 types:
Instrument for neonatal cases (aged <4 weeks)
Instrument for Infant and child cases (aged 4 weeks to 14 years)
Instrument for Adult cases (aged 15 years and over)
4.3. Organization of SRS
Implementation of the Indonesian SRS is coordinated by the Center for Health Systems and
Policy Research & Development – National Institute of Health Research & Development,
Ministry of Health in collaboration with the Directorate General of Population and Civil
Registry - Ministry of Home Affairs.
Indonesian SRS 2014 9
5. RESULTS
The Indonesian SAMPLE REGISTRATION SYSTEM (SRS) 2014, covers 128 subdistricts in 119
Districts or cities (30 provinces). Total population covered is about 3.5 % of the Total
National Population (240 million), that is 8,898,429, based on 2014 Social Security Data with
unique population ID Number (NIK).
Issuance of the Joint Decree of the Minister of Home Affairs and the Minister of Health
(2010) on Reporting of Death and Cause of Death and sharing of mortality data at the
grassroot level, facilitates the recording and reporting of birth and death events and
cooperation between the two sectors (Home Affairs and Health) at all levels.
Summary of Findings:
1. Total death cases found from January 1, 2014 to December 30, 2014: 41,590
2. Total population observed: 8,898,429
3. Total death cases (Data Analysis), consist of:
a. Aged 0-28 days : 927 cases
b. Aged 29 days-14 years : 1,065 cases
c. Aged 15 years and above : 39,598 cases
4. CDR of 6.4 per 1,000 population (projected from 2010 Population Census) used to set
national target of SRS (National Projection for 2014)
Crude coverage of SRS: 70 %
5. Number of Early Neonatal Death: 768 cases
Number of Intra Uterine Foetal Death (IUFD) : 490 (excluded in analysis)
Total Number of Perinatal Death: 1,258 cases
Denominators are based on:
Collected population data and live birth data in 128 SRS sites, adjusted by projection from
the 2010 Population Census for 2014 & updated Population Administration data from the
Ministry of Home Affairs.
Indonesian SRS 2014 10
5.1. Health Outcome Indicators
Health outcome indicators in 2014 are calculated, using the results of the Sample
Registration System 2014 with denominators being the population and live births of the
sample area in the same year.
These include: Crude Death Rate (CDR), Maternal Mortality Ratio (MMR), Neonatal Mortality
Rate (NMR), Early Neonatal Mortality Rate (ENMR), Infant Mortality Rate (IMR), Under Five
Mortality Rate (U5MR) and Child Mortality Rate (CMR).
Table 5.1 : Health Outcome Indicators (With Adjustment), Indonesia 2014
Indicators Est SE 95% CI RSE (%) LB UB
CDR Adjusted 7.48 0.31 6.87 8.09 4.1
MMR Adjusted 244.64 26.20 192.79 296.49 10.7
NMR Adjusted 12.88 1.10 10.70 15.07 8.5
ENMR Adjusted 10.59 0.98 8.65 12.53 9.3
IMR Adjusted 18.64 1.50 15.68 21.60 8.0
U5MR Adjusted 22.93 1.85 19.26 26.60 8.1
CMR Adjusted 4.30 0.55 3.20 5.39 12.8
The results show that after adjustment for under-reporting, the outcome indicators for 2014
are as follow:
Crude Death Rate (CDR): 7.48 per 1,000 population (95% CI: 6.87-8.09)
Maternal Mortality Ratio (MMR): 244.64 per 1,000 live births (95% CI: 192.79-296.49)
Neonatal Mortality Rate (NMR): 12.88 per 1,000 live births (95% CI: 10.70-15.07)
Early Neonatal Mortality Rate (ENMR): 10.59 per 1,000 live births (95% CI: 8.65-12.53)
Infant Mortality Rate (IMR): 18.64 per 1,000 live births (95% CI: 15.68-21.60)
Under Fives Mortality Rate (U5MR): 22.93 per 1,000 live births (95% CI: 19.26-26.60)
Child Mortality Rate (CMR): 4.30 per 1,000 live births (95% CI: 3.20-5.39)
Indonesian SRS 2014 11
Tabel 5.2 : Progress of Health Outcome Indicators (MDGs: 1991 & 2015); DHS 2012 & SRS 2014
No Outcome Indicators Baseline 1991
DHS 2012
SRS 2014
Target 2015
1 Neonatal Mortality Rate 32 19 12.88
2 Early Neonatal Mortality Rate 10.59
3 Infant Mortality Rate (1q0) 68 32 18.64 23
4 Child Mortality Rate (4q1) 34 9 4.30
5 Under-5 Mortality Rate (5q0) 97 40 22.93 32
6 Maternal Mortality Ratio (MMR) 390 359 244.64 102
This Table shows the progress of selected health outcome indicators from 1991 to 2014; and
the Millennium Development Goals 4 and 5 in 2015. All targets show improvement over the
time period covered and all have been reduced to below 2015 targets except the Maternal
Mortality Ratio.
Indonesian SRS 2014 12
Tabel 5.3 : Distribution of Proportion of Deaths by Sex and Age Group, Indonesian SRS 2014
Age Groups Sex
Total
Male Female
< 1 days 1.0 0.7 0.9
1 - 7 days 1.1 0.8 1.0
8 – 28 days 0.4 0.4 0.4
1 – 11 months 1.1 0.8 1.0
12 – 59 months 0.7 0.7 0.7
5 – 9 years 0.4 0.3 0.3
10 – 14 years 0.5 0.6 0.5
15 – 19 years 1.5 1.1 1.3
20 – 24 years 1.7 1.2 1.5
25 – 29 years 1.8 1.6 1.7
30 – 34 years 2.4 2.1 2.3
35 – 39 years 2.8 2.5 2.6
40 – 44 years 4.2 3.8 4.0
45 – 49 years 5.9 5.3 5.6
50 -54 years 8.3 7.3 7.9
55 – 59 years 9.6 8.2 9.0
60 – 64 years 10.9 9.0 10.0
65 – 69 years 9.6 9.3 9.5
70 – 74 years 12.0 12.1 12.0
75 – 79 years 9.0 9.5 9.2
80 – 84 years 7.5 10.5 8.9
≥ 85 years 7.4 12.1 9.6
The table show the distribution of proportion of deaths by sex and age group in the SRS Area
in 2014.
Indonesian SRS 2014 13
Figure 5.1 : Distribution of Proportion of Deaths by Sex and Age Group, Indonesian SRS 2014
Figure 5.2 : Distribution of Deaths by Place of Event, Indonesian SRS, 2014
Indonesian SRS 2014 14
The highest proportion of deaths occurred at homes (64.5 %), followed by at hospitals (30.1
%), other places (3.4 %) and at other health facilities (1.5 %).
Table 5.4 : Twenty Leading Underlying Causes of Death (Males & Females),
Indonesian SRS, 2014
No Cause of Death (ICD 10) %
1 Cerebrovascular diseases (I60 - I69) 21.1
2 Ischaemic heart diseases (I20 – I25) 12.9
3 Diabetes mellitus with complication (E10 – E14) 6.7
4 Respiratory tuberculosis (A15 – A16) 5.7
5 Hypertensive diseases with complication (I11 – I13) 5.3
6 Chronic lower respiratory diseases (J40-J47) 4.9
7 Diseases of the liver (K70 – K76) 2.7
8 Transport accidents (V01– V99) 2.6
9 Pneumonia (J12 – J18) 2.1
10 Diarrhoea and gastroenteritis of presumed infectious origin (A09) 1.9
11 Malnutrition (E40 – E46) 1.2
12 Falls (W00 – W19) 1.2
13 Malignant neoplasm of breast (C50) 1.0
14 Disorders relating to length of gestation and fetal growth (P05– P07) 0.9
15 Malignant neoplasm of liver and intrahepatic bile ducts (C22) 0.7
16 Viral hepatitis (B15 – B19) 0.6
17 Intrauterine hypoxia and birth asphyxia (P20 - P21) 0.6
18 Gastric and duodenal ulcer (K25-K27) 0.6
19 Malignant neoplasm of trachea, bronchus and lung (C33 - C34) 0.6
20 Malignant neoplasm of cervix uteri (C53) 0.5
This Table shows that cerebrovascular diseases, Ischaemic Heart Diseases, Diabetes Mellitus
with complications and Respiratory Tuberculosis were the leading underlying causes of death
for both sexes in 2014.
Indonesian SRS 2014 15
Table 5.5 : Twenty Leading Underlying Causes of Death among Males Indonesian SRS, 2014
No Cause of Death (ICD 10) %
1 Cerebrovascular diseases (I60 – I69) 19.0
2 Ischaemic heart diseases (I20 – I25) 14.7
3 Respiratory tuberculosis (A15 – A16) 7
4 Chronic lower respiratory diseases (J40 – J47) 6.1
5 Diabetes mellitus with complications (E10 – E14) 5.5
6 Hypertensive diseases with complications (I11 – I13) 4.9
7 Transport accidents (V01 – V99) 3.7
8 Diseases of the liver (K70 – K76) 3.2
9 Pneumonia (J12 – J18) 2.1
10 Diarrhoea and gastroenteritis of presumed infectious origin (A09) 1.7
11 Falls (W00 – W19) 1.2
12 Malignant neoplasm of liver and intrahepatic bile ducts (C22) 1.0
13 Disorders relating to length of gestation and fetal growth (P20 – P21) 0.9
14 Malnutrition (E40 – E46) 0.8
15 Viral hepatitis (B15 – B19) 0.8
16 Malignant neoplasm of trachea and lung (C33 – C34) 0.8
17 Intrauterine hypoxia and birth asphyxia (P20 – P21) 0.7
18 Gastric and duodenal ulcer (K25 – K27) 0.5
19 Malignant neoplasm of lip, oral cavity and pharynx (C00 – C14) 0.5
20 Malignant neoplasm of colon, rectum and anus (C18 – C21) 0.4
This Table shows that cerebrovascular diseases, Ischaemic Heart Diseases, Respiratory
Tuberculosis, Chronic lower respiratory diseases and Diabetes Mellitus with complications
were the leading underlying causes of death among males in 2014.
Indonesian SRS 2014 16
Table 5.6 : Twenty Leading Underlying Causes of Death among Females, Indonesian SRS, 2014
No Cause of Death (ICD 10) %
1 Cerebrovascular diseases (I60 – I69) 23.5
2 Ischaemic heart diseases (I20 – I25) 10.9
3 Diabetes mellitus with complications (E10 – E14) 8.1
4 Hypertensive diseases with complications (I11 – I13) 5.8
5 Respiratory tuberculosis (A15 – A16) 4.0
6 Chronic lower respiratory diseases (J40 – J47) 3.7
7 Diseases of the liver (K70 – K76) 2.1
8 Pneumonia (J12 – J18) 2.0
9 Diarrhoea and gastroenteritis of presumed infectious origin (A09) 2.0
10 Malignant neoplasm of breast (C50) 2.0
11 Malnutrition (E40 – E46) 2.0
12 Malignant neoplasm of cervix uteri (C53) 1.1
13 Falls (W00 – W19) 1.1
14 Anaemias (D50 – D64) 1.0
15 Transport accidents (V01 – V99) 1.0
16 Disorder relating to length of gestation and fetal growth (P05 – P08) 0.8
17 Direct obstetric deaths (O10 – O92) 0.7
18 Gastric and duodenal ulcer (K25 – K27) 0.6
19 Intrauterine hypoxia and birth asphyxia (P20 – P21) 0.5
20 Malignant neoplasm of liver and intrahepatic bile ducts (C22) 0.5
This Table shows that cerebrovascular diseases, Ischaemic Heart Diseases, Diabetes Mellitus
with complications, Hypertensive diseases with complications and Respiratory Tuberculosis
were the leading underlying causes of death among females in 2014.
Indonesian SRS 2014 17
Maternal Mortality
76.9
23.1
Direct Obstetric DeathsIndirect Obstetric Deaths
Figure 5.3 : Distribution of Maternal Mortality (%) by Direct and Indirect Obstetric Deaths, Indonesian SRS, 2014
There were 182 cases of maternal deaths and 4 cases of late maternal deaths (O96).
The Table below shows the distribution of maternal mortality by cause. Edema, proteinuria
and hypertensive disorders in pregnancy, childbirth and the puerperium; Maternal
haemorrhage and Maternal sepsis and infections were the most common causes of maternal
deaths
Indonesian SRS 2014 18
Table 5.7 : Distribution of Maternal Mortality By Cause, Indonesian SRS, 2014
No Causes of Maternal Death ICD 10 %
1 Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium
O10 – O16 37.4
2 Maternal haemorrhage O46, O67, O72 16.9 3 Maternal sepsis and maternal infections O85, O98 11.5 4 Complications of the pregnancy, labour,
delivery and puerperium O21, O44, O45, O48, O61, O62, O71, O75, O87, O88, O90
12.9 5 Maternal abortive outcome O01, O03, O06 3.8 6 Other maternal diseases classifiable elsewhere
but complicating pregnancy, childbirth and the puerperium
O99
17.5
74.7
19.2
3.8 2.2
Hospitals Homes Others Other Health Facilities
Figure 5.4: Distribution of Maternal Deaths by Place of Death, Indonesian SRS, 2014
Indonesian SRS 2014 19
Figure 5.4 shows the Distribution of Maternal Deaths By Place of Death. Most maternal
deaths occurred at the hospital (74.7 %), followed by at home (19.2 %).
Neonatal Mortality Table 5.8 : Leading Underlying Causes of Neonatal deaths, Indonesian SRS, 2014
No Causes of Death (ICD 10) %
1 Disorders relating to length of gestation and fetal growth (P05, P07, P08)
38.8
2 Intrauterine hypoxia and birth asphyxia (P20, P21) 26.5
3 Congenital malformations (Q00 – q99) 12.7
4 Other respiratory conditions of newborn (P24, P25, P28) 4.0 5 Heorrhagic, hematological disorders, kern ikhterus,
neonatal jaundice (P51, P52, P55, P57, P59) 2.2
6 Pneumonia (J18) 2.0 7 Fetus and newborn affected by maternal factors and by
complications of pregnancy labour and delivery (P01, P02, P03)
1.6
8 Respiratory distress of newborn (P22) 1.1
9 Congenital pneumonia (P23) 1.0 10 Diarrhoea and gastroenteritis of presumed infectious
origin (A09) 0.8
Table 5.8, shows the leading underlying causes of death among neonates. The most common
causes are Disorders relating to length of gestation and fetal growth, Intrauterine hypoxia
and birth asphyxia, and Congenital malformations.
Indonesian SRS 2014 20
Table 5.9: Leading Underlying Causes of Death among Early Neonates (0-7 days), Indonesian SRS, 2014
No Causes of Death (ICD 10) %
1 Disorders relating to length of gestation and fetal growth (P05, P07, P08) 40.8
2 Intrauterine hypoxia and birth asphyxia (P20, P21) 30.9
3 Other respiratory conditions of newborn (P24, P25, P28) 4.2
4 Congenital malformations (Q00 – Q99) 1.8 5 Fetus and newborn affected by maternal factors and by complications of
pregnancy labour and delivery (P01, P02, P03)
1.4
6 Heorrhagic, hematological disorders, kern ikhterus, neonatal jaundice (P51, P52, P55, P57, P59)
1.4
7 Congenital pneumonia (P23) 1.0
8 Respiratory distress of newborn (P22) 0.9
9 Tetanus neonatorum (A33) 0.5
10 Sudden infant death syndrome (R95) 0.5
Table 5.9, shows the leading underlying causes of death among early neonates (0-7 days) in
2014. `Disorders relating to length of gestation and fetal growth, Intrauterine hypoxia and
birth asphyxia and Other respiratory conditions of newborn are the most common causes.
Indonesian SRS 2014 21
Table 5.10 : Leading Underlying Causes of Death among Late Neonates (8-28 days), Indonesian SRS, 2014
No Causes of Death (ICD 10) %
1 Disorders relating to length of gestation and fetal growth (P05, P07, P08)
29.6
2 Congenital malformations (Q00 – q99) 17.0
3 Pneumonia (J18) 11.3 4 Intrauterine hypoxia and birth asphyxia (P20, P21) 5.7
5 Haemorrhagic, hematological disorders, kern ikhterus, neonatal jaundice (P51, P52, P55, P57, P59)
5.7
6 Diseases of the digestive system (K56, K57, K92)
3.1
7 Other respiratory conditions of newborn (P24, P25, P28) 3.1
8 Diarrhoea and gastroenteritis of presumed infectious origin (A09)
2.5
9 Fetus and newborn affected by maternal factors and by complications of pregnancy, labour and delivery (P01, P02, P03)
2.5
10 Bacterial sepsis of newborn (P36) 2.5
Table 5.10, shows the leading underlying causes of death among late neonates (8-28 days) in
2014. `Disorders relating to length of gestation and fetal growth, congenital malformation
and Pneumonia are the most prevalent causes.
Indonesian SRS 2014 22
Figure 5.5: Proportion of Neonatal Deaths by Place of Death, Indonesian SRS 2014
Figure 5.5, shows the Proportion of neonatal deaths by place of death. The majority
occurred at hospitals, followed by homes and other heath facilities.
Infant Mortality
Table 5.11 : Leading Underlying Causes of Death among Infants, Indonesian SRS, 2014
No Causes of Death (ICD 10) %
1 Intrauterine hypoxia and birth asphyxia (P20, P21)
18.3
2 Pneumonia (J18)
8.7
3 Diarrhoea and gastroenteritis of presumed infectious origin (A09) 6.5 4
Congenital malformations of the heart (Q21, Q23, Q24) 4.1
5 Meningitis (G03) 2.0 6 Diseases of the digestive system (K46, K56, K57, K63, K74, K75, K83,
K92) 1.9
7 Fetus and newborn affected by maternal factors and by complications of pregnancy labour and delivery (P01, P02, P03)
1.7
8 Haemorrhagic and haematological disorders of fetus and newborn/Haemorrhagic disorder, kern ichterus, jaundice (P51, P52, P55, P57, P59)
1.6 9
Respiratory distress of newborn (P22) 0.8
10 Congenital hydrocephalus and spina bifida (Q03, Q05)
0.8
Indonesian SRS 2014 23
Table 5.11, shows the leading underlying causes of death among infants. Intrauterine
hypoxia and birth asphyxia; Pneumonia and Diarrhoea and gastroenteritis of presumed
infectious origin were the most common causes.
Child (Under five) Mortality Table 5.12 : Leading Underlying Causes of Death among Children Aged 1-4 Years,
Indonesian SRS, 2014
No Causes of Death (ICD 10) %
1 Diarrhoea and gastroenteritis of presumed infectious origin (A09) 17.2
2 Pneumonia (J12 - J18) 12.9
3 Meningitis (G03) 6.3
4 Diseases of the digestive system (K46, K56, K57, K63, K74, K75, K83, K92) 4.3
5 Accidental drowning and submersion (W65–W74) 4.3
6 Transport accidents (V02, V03, V22, V23, V27-V29, V33, V99) 3.0
7 Malnutrition and other nutritional deficiencies (E40, E41, E44, E46) 2.6
8 Congenital malformations of the heart (Q21, Q23, Q24) 2.6
9 Leukaemia (C91 – C95) 2.0
10 Tuberculosis (A16) 1.3
Table 5.12 , shows the leading underlying causes of death among children aged 1-4 years.
Diarrhoea and gastroenteritis of presumed infectious origin, Pneumonia and Meningitis
were the most common causes.
Indonesian SRS 2014 24
Table 5.13 : Leading Underlying Causes of Death among Children under five (aged 0-59 months), Indonesian SRS, 2014
No Causes of Death (ICD 10) %
1 Disorders relating to length of gestation and fetal growth/premature post-term (P05, P07, P08)
22.6
2 Intrauterine hypoxia and birth asphyxia (P20, P21)
14.9
3 Pneumonia (J12 - J18) 9.4 4 Diarrhoea and gastroenteritis of presumed
infectious origin (A09)
8.5 5 Congenital malformations of the heart (Q21,
Q23, Q24) 3.9
6 Meningitis (G03) 2.8 7 Diseases of the digestive system (K46, K56, K57, K63, K74,
K75, K83, K92)
2.3 8 Fetus and newborn affected by maternal factors and by
complications of pregnancy, labour and delivery (P01 – P03)
1.4
9 Haemorrhagic and haematological disorders of fetus and newborn/Haemorrhagic disorder, kern ichterus, Jaudice (P51, P52, P55, P57, P59)
1.3
10 Accidental drowning and submersion (W65 – W74) 0.9
Table 5.13, shows leading underlying causes of death among children under five (aged 0-59
months) in 2014. Disorders relating to length of gestation and fetal growth/premature post-
term is the highest, followed by Intrauterine hypoxia and birth asphyxia, Pneumonia and
Diarrhoea and gastroenteritis of presumed infectious origin
Indonesian SRS 2014 25
Children Aged 5 – 14 Years Table 5.14: Leading Underlying Causes of Death among Children Aged 5-14 Years, Indonesian SRS, 2014
No Causes of Death (ICD 10) %
1 Transport accidents (V02, V03, V22, V23, V27-V29, V33, V99)
10.7
2 Pneumonia (J12 - J18) 7.4
3 Accidental drowning and submersion (W65 – W74) 6.8
4 Diseases of the digestive system (K46, K56, K57, K63, K74, K75, K83, K92)
6.3
5 Leukaemia (C91 – C95) 5.2
6 Diarrhoea and gastroenteritis of presumed infectious origin (A09)
3.8
7 Meningitis (G03) 3.6
8 Congenital malformations of the heart (Q21, Q23, Q24) 3.0
9 Tuberculosis (A16) 1.9
10 Malnutrition and other nutritional deficiencies (E40, E41, E44, E46)
1.4
11 Congenital hydrocephalus (Q03) 0.8
12 Human immunodeficiency virus (HIV) disease (B20, B24) 0.5
13 Malaria (B50, B54) 0.5
14 Tetanus (A35) 0.3
15 Accidental poisoning by and exposure to noxious substances (X45)
0.3
Table 5.14 , shows the leading underlying causes of death among children aged 5-14 years in
2014.
The most prevalent cause was Transport accidents, followed by Pneumonia, Accidental
drowning and submersion, Diseases of the digestive system, Leukaemia and Diarrhoea &
gastroenteritis of presumed infectious origin.
Indonesian SRS 2014 26
Table 5.15: Leading Underlying Causes of Death among Population Aged 15-44 Years, Indonesian SRS, 2014
No Cause of Death (ICD 10) %
1 Transport accidents (V01 – V99) 11.2
2 Ischaemic heart diseases (I20 – I25) 10.0
3 Respiratory tuberculosis (A15 – A16) 9.3
4 Cerebrovascular diseases (I60 – I69) 7.8
5 Diseases of the liver (K70 – K76) 4.3
6 Diabetes mellitus with complication (E10 – E14) 3.7
7 Hypertensive diseases with complication (I11 – I13) 2.9
8 Human immunodeficiency virus/HIV disease (B20 – B24) 2.3
9 Malignant neoplasm of breast (C50) 2.2
10 Chronic lower respiratory diseases (J40 – J47) 2.1
11 Falls (W00 – W19) 1.5
12 Malignant neoplasm of meninges, brain and other parts of central nervous system (C70 – C72)
1.4
13 Viras hepatitis (B15 – B19) 1.4
14 Malignant neoplasm of liver and intrahepatic bile ducts (C22) 1.1
15 Diarrhea and gastroenteritis of presumed infectious origin (A09) 1.1
16 Malignant neoplasm of servix uteri (C53) 1.1
17 Leukaemia (C91 – C95) 0.9
18 Non Hodgkin’s lymphoma (C82 – C85) 0.9
19 Remainder of certain infectious and parasitic diseases (A21 – A32) 0.9
20 Accidental drowning and submersion (W69 – W70) 0.9
Table 5.15 , shows the leading underlying causes of death among the population aged 15-44
years in 2014. Transport accidents (V01 – V99) is the highest, followed by Ischaemic heart
diseases (I20 – I25), Respiratory tuberculosis (A15 – A16), Cerebrovascular diseases
(I60 – I69), Diseases of the liver (K70 – K76) and Diabetes mellitus with complication
(E10 – E14).
Indonesian SRS 2014 27
Table 5.16: Leading Underlying Causes of Death among Population Aged 45 - 59 Years, Indonesian SRS, 2014
No Cause of Death (ICD 10) %
1 Cerebrovascular diseases (I60 – I69) 21.0
2 Ischaemic heart diseases (I20 – I25) 15.8
3 Diabetes mellitus with complication (E10 – E14) 11.3
4 Respiratory tuberculosis (A15 – A16) 6.5
5 Hypertensive diseases with complication (I11 – I13) 5.7
6 Diseases of the liver (K70 – K76) 4.0
7 Chronic lower respiratory diseases (J40-J47) 3.5
8 Transport accidents (V01– V99) 2.5
9 Malignant neoplasm of breast (C50) 2.0
10 Falls (W00 – W19) 1.1
11 Malignant neoplasm of servix uteri (C53) 1.0
12 Malignant neoplasm of liver and intrahepatic bile ducts (C22) 1.0
13 Diarrhoea and gastroenteritis of presumed infectious origin (A09) 1.0
14 Malignant neoplasm of trachea and lung (C33, C34) 0.9
15 Pneumonia (J12 – J18) 0.8
. Table 5.16 , shows the leading underlying causes of death among the population aged
45 - 59 years in 2014. Cerebrovascular diseases is ranked the first, followed by Ischaemic
heart diseases (I20 – I25), Diabetes mellitus with complication (E10 – E14), Respiratory
tuberculosis (A15 – A16), Hypertensive diseases with complication (I11 – I13), and Diseases
of the liver (K70 – K76).
Indonesian SRS 2014 28
Table 5.17: Leading underlying causes of death among the elderly aged 60 + years, Indonesian SRS, 2014
No Cause of Death (ICD 10) %
1 Cerebrovascular diseases (I60 – I69) 25.9
2 Ischaemic heart diseases (I20 – I25) 13.5
3 Chronic lower respiratory diseases (J40-J47) 6.5
4 Diabetes mellitus with complication (E10 – E14) 6.2
5 Hypertensive diseases with complication (I11 – I13) 6.2
6 Respiratory tuberculosis (A15 – A16) 5.0
7 Pneumonia (J12 – J18) 2.3
8 Diseases of the liver (K70 – K76) 2.0
9 Diarrhoea and gastroenteritis of presumed infectious origin (A09) 2.0
10 Malnutrition (E40 – E46) 1.9
11 Falls (W00 – W19) 1.2
12 Transport accidents (V01– V99) 0.7
13 Gastric and duodenal ulcer (K25, K27) 0.6
14 Malignant neoplasm of liver (C22) 0.5
15 Malignant neoplasm of trachea and lung (C33, C34) 0.5
Table 5.17, shows leading underlying causes of death among the elderly aged 60 years and
above in 2014.
Cerebrovascular diseases is ranked the first, followed by Ischaemic heart diseases (I20 – I25),
Chronic lower respiratory diseases (J40-J47), Diabetes mellitus with complication
(E10 – E14), Hypertensive diseases with complication (I11 – I13) and Respiratory tuberculosis
(A15 – A16).
Indonesian SRS 2014 29
Figure 5.6 : Distribution of Mortality due to Cerebrovascular Diseases (Stroke) by Age Group, Indonesian SRS, 2014
Figure 5.6, shows that in 2014 Cerebrovascular dIseases (Stroke - one of the main causes of
mortality) started at the age group of 30 – 34 years and kept increasing with the peak at age
group of 70 – 74 years.
Indonesian SRS 2014 30
Figure 5.7 : Distribution of Mortality due to Ischaemic Heart Disease by Age Group, Indonesian SRS, 2014
Figure 5.7 , shows that in 2014 Ischaemic Heart Diseases as one of the the main cause of
mortality; started at the age group 25 - 29 years and keep increasing with the first peak at
60 – 64 years, and the second peak at 70 – 74 years age group.
Indonesian SRS 2014 31
Table 5.18 : Distribution of Injury Mortality by External Causes, Indonesian SRS, 2014
No Cause of Death %
1 Transport accidents 51.5
2 Falls 23.0
3 Intentional self-harm 4.7
4 Accidental drowning and submersion 4.3
5 Assault 2.8
6 Accidental poisoning by and exposure to noxious substances 2.2
7 Exposure to smoke, fire and flames 1.0
8 All other external causes 10.6
Total 100.0
Table 5.18, shows the distribution of injury mortality by external causes in 2014.
Transport accidents ranked first, followed by Falls, Intentional self-harm and accidental
drowning and submersion.
Figure 5.8: Distribution of Mortality due to Transport Accidents by Age Group, Indonesian SRS, 2014
Indonesian SRS 2014 32
Figure 5.8, shows the distribution of mortality due to transport accidents by age
group in 2014. The highest mortality found at 15 – 19 years age group, followed by
25 – 29 years age group and 50 – 54 years age group.
Table 5.19 : Distribution of Injury Mortality by Type of Transport, Indonesian SRS, 2014
No Cause of Death %
1 Motorcycle rider 52.6
2 Pedestrian 14.2
3 Car 3.1
4 Pedal cyclist 1.7
5 Occupant of three-wheeled motor vehicle 1.6
6 Other land transport accidents (train, ect) 1.0
7 Water transport accidents 0.8
8 Occupant of pick-up truck or van 0.7
9 Occupant of heavy transport vehicle 0.2
10 Bus occupant 0.2
11 Unspecified transport accidents 0.2
Total 100.0
Table 5.19, shows the distribution of injury mortality by type of transport in 2014.
The most prevalent mortality cases were motorcycle riders, followed by pedestrians, cars,
pedal cyclists and occupants of three-wheeled motor vehicle.
Indonesian SRS 2014 33
Table 5.20: Proportion of Deaths due to HIV/AIDS, Tuberculosis and Malaria from Total Deaths, Indonesian SRS, 2014
No Cause of Death %
1 HIV/AIDS 0.4
2 Tuberculosis 5.7
3 Malaria 0.1
Table 5.20, shows the proportion of deaths due to HIV/AIDS, Tuberculosis and Malaria from
total deaths in 2014.
Tuberculosis ranked first, followed by HIV/AIDS and Malaria.
Indonesian SRS 2014 34
6. CONCLUSIONS
POLICY IMPLICATIONS OF THE FINDINGS
Indonesia needs to accelerate efforts to improve population health status. To accelerate
reduction of the Burden of Non Communicable Disease and Injuries, special efforts should
be prioritized, planned and implemented; among others:
Control of major risk factors of Non-Communicable Diseases: unhealthy diet including
reduction of salt consumption and avoiding high total cholesterol food, controlling high
blood pressure and smoking behavior
Special preventive efforts by the health sector and other related sectors should be carried
out to control road traffic injuries and other unnatural deaths
Unfinished Agenda for Neonatal, Infant, Child and Maternal Mortality
Despite sustained and rapid reduction in child mortality, a substantial fraction of the burden
of disease is due to premature mortality in children. Neonatal causes, diarrhea and
pneumonia are the major causes. There is a need to introduce low cost & simple
Resuscitation Kits for asphyxiated babies in standard midwifery kits, to incorporate PCV-13
and Rotavirus Vaccines in routine immunization program, revitalization of community
knowledge & practices on diarrhea management and use of ORT
Improvement in the quality and quantity of maternity and neonatal care through Basic and
Comprehensive Emergency Maternal and Neonatal Care (PONED & PONEK facilities) is
urgently needed as well as the referral system; these require improved, integrated and
comprehensive efforts. Promotion of Ultrasound use by trained midwives in Puskesmas and
Polindes, is also needed to assist early identification of selected obstetric complications.
CONTROL OF STROKE Stroke is not only the top leading cause of mortality (21.1 % of total); it is also the disease
with the biggest gap between Indonesia and comparator countries.
Indonesian SRS 2014 35
Key factors include high level of hypertension, high tobacco consumption, poor diet
especially high sodium and glucose consumption and low fruit consumption, lack of physical
activity as well as the inadequate management of Diabetes Mellitus
Two key strategies to curb high stroke rates are:
1. Risk factor reduction through public health campaign, taxation and legislation.
2. Blood pressure management through effective diagnosis, treatment and follow up in
primary care facilities
ACCELERATING PROGRESS ON TUBERCULOSIS CONTROL Despite a 37% reduction in age-standardized tuberculosis death rates between 1990 and
2010, TB is the fourth leading cause of mortality, with 5.7 % of total cases. Results of 2013-
2014 TB Prevalence Survey showed a prevalence of 759 per 100,000 population, significantly
higher (more than doubled) when compared with previous findings
Case detection rates need to be increased through better diagnostic capabilities in the
peripheral health system facilities (chest X-Ray, bacteriological culture, training of personnel)
Given the unusually high burden of tuberculosis in Indonesia over decades, other strategies
including management of Multi Drug Resistant Cases (MDR) and Co-infection with HIV
should be considered.
ROAD TRAFFIC INJURIES Road traffic injuries (dominated by motor-cycles) are the main cause of injury burden and
rates have been consistently high. At present, road traffic injury causes about 30,000 annual
deaths nationally and has the potential for burden reduction.
Indonesia has the highest rates of road traffic injuries among comparator nations.
Successful multi-sector approaches to reduce road traffic injuries are needed, including road
safety engineering, traffic calming, separation of pedestrians from traffic, seat-belt & helmet
law enforcement, and enforcement of vehicle safety standards.
Indonesian SRS 2014 36
MASSIVE RISE OF DIABETES AND CHRONIC KIDNEY DISEASES Incidence of Diabetes Mellitus and Chronic Kidney Diseases have increased by 86% and 90%
respectively in the last 25 years. Disease burden and health care expenditures on these
conditions will steadily grow and the cost per case is very high. Prevention strategies such as
encouraging routine physical activity and weight reduction need to be accelerated.
Indonesia needs to enhance the management of complications, such as retinopathy,
nephropathy, neuropathy and cardiovascular complications, through improved primary care
programs.
TOBACCO CONTROL Tobacco consumption is still high in Indonesia, 36.3 % of population and 65 % of males alone
are active smokers (Basic Health Research/Riskesdas 2013). The rising burden in men means
that tobacco’s toll in Indonesia is nearly equal to the developed country situation in 1990.
The tobacco attributable disease burden will continue to rise due to current patterns of
consumption and inadequate tobacco control efforts. Future costs in terms of cardiovascular
and cerebrovascular diseases, cancers and other tobacco related diseases will be very large.
Intensified tobacco control efforts following the MPOWER/ WHO Policy package and FCTC
are urgently needed
IMPLICATIONS FOR NATIONAL HEALTH INSURANCE (JKN) The burden of disease in terms of incidence and prevalence of Non Communicable Diseases
and Injuries, along with information on likely costs per case treated, should be used to
forecast the financial burdens that should be expected due to the demographic and
epidemiological transition.
Instituting disease expenditure tracking and linkage to ongoing updates of the burden of
disease should be used to anticipate high health care costs, including the burden for the
health sector and the National Health Insurance (BPJS - JKN).
Indonesian SRS 2014 37
EXIT STRATEGY OF SRS: CIVIL REGISTRATION & VITAL STATISTICS (CRVS) The development of Civil Registration and Vital Statistics (CRVS) is being used as an exit
strategy for the SRS in 7 Districts/Cities in 2014-2015; applying “Universal Coverage”
approach of civil registration and using “Paperless Method” (Tablet Computer and PC). IHME
(Institute of Health Metrics and Evaluation, Seattle, USA) - Verbal Autopsy Data Collection &
Diagnosis softwares (PHMRC & SMART VA) are being used and later will be updated with
2014 WHO VA Instruments & softwares. Internet/Flash-Disk/SD Card are used to send
collected data to District/City Health Offices.
Civil Registration Data will be used for producing Vital Statistics at city and district level.
CRVS incorporates all sources of Vital Registry, namely: Hospital data (multiple causes of
death based on ICD-10), Community based mortality data (Verbal Autopsy) for those who
died in the community and unnatural death data from Local Police and Forensic Department
of local Hospitals.
Indonesian SRS 2014 38
REFERENCES
International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, World Health Organization, Geneva 1992. Verbal autopsy standards : ascertaining and attributing cause of death, WHO 2007 Village Potency Survey 2008, Central Bureau of Statistics - BPS, Jakarta 2008 Indonesia Population Projection, 2010-2035. BPS – Statistics Indonesia, Jakarta 2013 S. Preston KH. Estimating the completeness of death registration. Population Studies: A Journal of Demography. 1980;34(2):18. Christopher JL Murray JKR, Jacob Marcus, Thomas Laakso, Alan D. Lopez. What Can We Conclude from Death Registration? Improved Methods for Evaluating Completeness. PloS Medicine. 2010. Christopher JL Murray, Alan D Lopez, Kenji Shibuya, Rafael Lozano. Verbal autopsy: advancing science, facilitating application (Editorial). Population Health Metrics 2011, 9:18 (27 July 2011) Daniel Chandramohan. Validation and validity of verbal autopsy procedures (Commentary). Population Health Metrics 2011, 9:22 (1 August 2011) Philip W. Setel, Osman Sankoh, Chalapati Rao, Victoria A. Velkoff, Colin Mathers, Yang Gonghuan, et al. Sample registration of vital events with verbal autopsy: a renewed commitment to measuring and monitoring vital statistics. Bulletin of WHO. 2005;83(8):7.
Philip W. Setel. Verbal Autopsy and global mortality statistics: if not now, then when?.
Population Health Metrics 2011, 9:20 (27 July 2011)
Sheila S Mudenda et al. Feasibility of using a World Health Organization-standard
methodology for Sample Vital Registration with Verbal Autopsy (SAVVY) to report
leading causes of death in Zambia: results of a pilot in four provinces, 2010.
Population Health Metrics 2011, 9:40 (5 August 2011)
Indonesian SRS 2014 39
ANNEX 1
LIST OF DISTRICT & CITY, SUBDISTRICT AND NUMBER OF POPULATION OF SRS SITE, INDONESIA 2014
Indonesian SRS 2014 40
DISTRICT ID CODE NAME OF DISTRICT NAME OF SUBDISTRICT
1101010 SIMEULUE TEUPAH SELATAN 1109100 PIDIE TANGSE 1115030 NAGAN RAYA BEUTONG 1204080 TAPANULI TENGAH MANDUAMAS 1208070 ASAHAN AIR BATU 1211130 KARO BARUSJAHE 1213030 LANGKAT SEI BINGAI 1218051 SERDANG BEDAGAI TEBING SYAHBANDAR 1303050 SOLOK LEMBAH GUMANTI 1308021 LIMA PULUH KOTA LAREH SAGO HALABAN
1403011 INDRAGIRI HILIR KEMUNING 1406080 KAMPAR SIAK HULU 1501060 KERINCI SUNGAI PENUH 1508010 TEBO TEBO ILIR 1603040 MUARA ENIM LAWANG KIDUL 1606090 MUSI BANYUASIN SUNGAI LILIN
1609090 OGAN KOMERING ULU TIMUR SEMENDAWAI SUKU III
1705041 SELUMA SELUMA SELATAN 1802110 TANGGAMUS CUKUH BALAK 1804100 LAMPUNG TIMUR PEKALONGAN 1806080 LAMPUNG UTARA SUNGKAI UTARA 1901090 BANGKA SUNGAI LIAT
3201030 BOGOR PAMIJAHAN 3201180 BOGOR CILEUNGSI 3201280 BOGOR JASINGA 3202211 SUKABUMI CICANTAYAN 3203150 CIANJUR SUKALUYU 3204090 BANDUNG CIKANCUNG 3204280 BANDUNG BOJONGSOANG 3205200 GARUT KARANGPAWITAN 3206161 TASIKMALAYA GUNUNGTANJUNG 3207221 CIAMIS SINDANGKASIH 3209040 CIREBON BABAKAN 3209230 CIREBON GEGESIK
3211061 SUMEDANG GANEAS 3212170 INDRAMAYU LOHBENER 3213210 SUBANG LEGONKULON 3215090 KARAWANG LEMAHABANG 3216070 BEKASI CIBITUNG 3217070 BANDUNG BARAT BATUJAJAR
Indonesian SRS 2014 41
ID CODE NAME OF DISTRICT NAME OF SUBDISTRICT
3301120 CILACAP KAWUNGANTEN 3302160 BANYUMAS PEKUNCEN 3304030 BANJARNEGARA MANDIRAJA 3305180 KEBUMEN SEMPOR 3307130 WONOSOBO KEJAJAR 3309120 BOYOLALI NOGOSARI 3311030 SUKOHARJO TAWANGSARI 3312240 WONOGIRI GIRIMARTO 3315010 GROBOGAN KEDUNGJATI 3316090 BLORA JEPON 3318110 PATI GABUS 3320070 JEPARA TAHUNAN 3322031 SEMARANG KALIWUNGU
3324080 KENDAL KALIWUNGU 3326110 PEKALONGAN BOJONG 3327130 PEMALANG ULUJAMI 3329030 BREBES BUMIAYU 3401050 KULON PROGO LENDAH 3403140 GUNUNG KIDUL NGAWEN 3502050 PONOROGO SAWOO 3504080 TULUNGAGUNG REJOTANGAN 3505210 BLITAR WONODADI 3507040 MALANG BANTUR 3507280 MALANG SINGOSARI 3509040 JEMBER WULUHAN
3509730 JEMBER PATRANG 3511040 BONDOWOSO PUJER 3513140 PROBOLINGGO BESUK 3514220 PASURUAN GRATI 3516010 MOJOKERTO JATIREJO 3517130 JOMBANG JOMBANG 3519060 MADIUN KARE 3521130 NGAWI KEDUNGGALAR 3523070 TUBAN SOKO 3524200 LAMONGAN KARANG GENENG 3526070 BANGKALAN GALIS 3528060 PAMEKASAN PROPPO 3601061 PANDEGLANG SOBANG
3602160 LEBAK WARUNGGUNUNG 3603100 TANGERANG CIPUTAT 3603210 TANGERANG KOSAMBI 5102020 TABANAN KERAMBITAN 5107040 KARANG ASEM KARANGASEM 5202020 LOMBOK TENGAH PUJUT
Indonesian SRS 2014 42
ID CODE NAME OF DISTRICT NAME OF SUBDISTRICT
5203090 LOMBOK TIMUR AIKMEL 5303111 KUPANG NEKAMESE 5309072 FLORES TIMUR WITIHAMA 5319010 MANGGARAI TIMUR BORONG 6105150 SANGGAU TAYAN HILIR 6112050 KUBU RAYA SUNGAI KAKAP 6209090 KATINGAN SANAMAN MANTIKEI 6307060 HULU SUNGAI TENGAH LABUAN AMAS SELATAN 6404010 KUTAI TIMUR MUARA ANCALONG 7105100 MINAHASA SELATAN TENGA 7205130 DONGGALA BALAESANG 7304021 JENEPONTO BONTORAMBA 7309070 PANGKAJENE KEPULAUAN LABAKKANG
7314080 SIDENRENG RAPPANG DUAPITUE 7325031 LUWU TIMUR TOMONI TIMUR 7408061 KOLAKA UTARA POREHU 7604030 MAMUJU KALUKKU 8204022 HALMAHERA SELATAN OBI TIMUR 9403230 JAYAPURA SENTANI
CITY ID CODE
NAME OF CITY NAME OF SUBDISTRICT
1171010 BANDA ACEH MEURAXA 1275050 MEDAN MEDAN AREA
1275200 MEDAN MEDAN MARELAN 1471010 PEKANBARU TAMPAN 1671021 PALEMBANG KERTAPATI 1771031 BENGKULU SUNGAI SERUT 2172010 TANJUNG PINANG BUKIT BESTARI 3171100 JAKARTA SELATAN SETIA BUDI 3172090 JAKARTA TIMUR PULO GADUNG 3174030 JAKARTA BARAT PALMERAH 3175040 JAKARTA UTARA KOJA 3273030 BANDUNG BOJONGLOA KALER 3273260 BANDUNG CIDADAP 3275061 BEKASI MEDAN SATRIA
3277020 KOTA CIMAHI CIMAHI TENGAH 3373040 SALATIGA SIDOREJO 3376010 TEGAL TEGAL SELATAN 3573050 MALANG LOWOKWARU 3578130 SURABAYA WIYUNG 3578281 SURABAYA PAKAL
Indonesian SRS 2014 43
ID CODE
NAME OF CITY NAME OF SUBDISTRICT
3672022 CILEGON PURWAKARTA 5371030 KUPANG OEBOBO 6471010 BALIKPAPAN BALIKPAPAN SELAT 7172011 BITUNG MATUARI 7371111 MAKASSAR TAMALANREA
Indonesian SRS 2014 44
ANNEX 2
MONITORING AND EVALUATION FRAMEWORK FOR SAMPLE REGISTRATION SYSTEM (SRS)
Indonesian SRS 2014 45
Indicator Name Baseline Target Data
Source Achievement
Percentage of Sub-Districts
submitting mortality report
with validated multiple causes
of death (using ICD-10)
1.5 % (2009)
24 % (2012)
63 % (2013)
84 % (2014)
SRS
100 % of
Subdistricts (128)
Indonesian SRS 2014 47
Weighting
Initial sampling design weight
Based on sampling methods in the SRS, the initial sampling design weight was calculated
using the formula:
: is the total population of Indonesia from Podes 2008
: is the number of population in the subdistrict from Podes 2008
n: is the number of selected subdistricts (n=128)
From the results of the weight calculation above, there is one subdistrict, Obi Timur, District
of Halmahera Selatan, which has a very different weight than the other districts. This can lead
to overestimation of the standard error. For adjustment to the sub-district level it is necessary
to maintain unchanged the estimated total population. This will affect the value of weights for
other districts.
Figure 1 below shows the result of a plot between the initial design weights with adjustment
(trimmed) weight for each district selected. Subdistricts are sorted by weight of the smallest
value.
Figure 1 Plot initial design weight and trimmed weight by subdistricts
Weight results are then used to calculate the estimated number of population by sex and age
group recording the results of the population in each subdistrict selected according to the
administration and population division, the Ministry of Home Affairs.
Indonesian SRS 2014 48
with:
is the estimated by sex j by age groups k
is trimmed weight of subdistrict i
is number of population 2014 (sources from the Ministry of home affair) at subdistricts
i, sex j, and age groups k
Results obtained from population counts approximate the total population in 2014 to be
246,648,142 with the male population being 126,393,358 and female population being
120,254,784. Estimates of population by age group and sex can be seen in Appendix 1. The
age and sex structure of the population estimates using data from the Ministry of Home
Affairs can be seen in Figure 2.
Figure 2 Distribution of the estimated number of population by age group, using data from
the Ministry of Home Affairs and using the trimmed weight
There was quite a large difference between the estimated population size using Ministry of
Interior data when compared to the estimated number of population according to the
projection in 2014 (BPS and Bappenas). The projection showed a population of 252,164,786
with a total population of 126,715,188 males and a female population of 125,449,598. This
difference is also seen in the age structure (see Figure 3). The results of 2014 population
projections by sex and age groups listed in Appendix 2.
Indonesian SRS 2014 49
Figure 3 Distribution of population by age group from projected population 2014
The results using SP 2010 data produce a population structure according to sex and age group
which is slightly different again, especially in the age group 15-24 years (see Figure 4).
Figure 4 Distribution of population by age group from SP 2010
From the comparison of the total population and the population structure according to sex and
age group, the team agreed to use the total population by gender based on the results of
Indonesian SRS 2014 50
projected population in 2014 and population age structure for each sex using SP 2010 results,
in calculating the adjustment weight. Adjustment weight by sex and age groups are needed in
order to ensure the total population according to the survey results are the same as the
population according to 2014 projections.
Sex-age specific cell adjustment weight
The sex-age specific cell adjustment weight ( ) is used as a control in order to ensure the
total population by gender and age group is equal to the total population by sex and age group
in the projected population for 2014.
with:
is trimmed weight of subdistrict i
is the estimated population by sex j age groups k from 2014 projected populations
is the estimated population by sex j age groups k from SP 2010
Results of counting the estimated number of population by sex and age groups using cell
adjustment weight can be found in Appendix 3 and the structure of age groups in Figure 5.
Figure 5 Distribution of survey result population by age group with cell adjustment weight
applied
Indonesian SRS 2014 51
For maternal mortality indicators, weight adjustment was calculated by the formula:
with:
is trimmed weight os subdistrict i
is the estimated population of women aged 15-49 years from 2014 projected results
is the estimated population of women aged 15-49 years from survey 2010
For infant and child mortality indicators, weight adjustment was calculated by the formula:
with:
is trimmed weight of subdistrict i
is the estimated number of population aged 0-4 year from 2014 projected results
is the estimated number of population aged 0-4 year from survey 2010
Under reporting adjustment weight
To calculate the weight adjustment for under-reporting we need to know the coverage level of
deaths reported in the SRS. However, this coverage number of reported deaths is unknown.
Using the Preston-Coale method the Construction of Life Table Indonesia report based on the
2010 Population Census data (Ezra Suhaimi, UNFPA, 2014, the report is limited) estimates
data coverage for deaths in SP2010 by province ranged from 10-57% (see Appendix 4)
Mortality data collection methods in SRS differ from the SP2010. Methods of data collection
in the SRS are believed to produce better coverage. This is because deaths are reported as
they occur whereas SP 2010 data quality is highly dependent on the memory of members of
the household when interviewed.
Results of a study of death registration completeness in 13 villages in Surakarta and 12
villages in the district of Pekalongan, Central Java showed that the levels of coverage of
reporting the incidence of death were respectively 61% and 81%. Assuming that both of these
areas represent the province of Central Java, the difference in the level of coverage in
reporting the incidence of death among SP2010 (45% for men and 39% for women) and SRS
in Central Java can be calculated as follows:
Assuming that the difference in the level of coverage of reporting the incidence of death in
SP2010 and SRS in Central Java province is the same as the other provinces, the rate of
coverage of SRS mortality incident reporting in other provinces can be estimated with:
Indonesian SRS 2014 52
Calculation of total deaths is carried out using the formula:
with:
D is the total estimated deaths
d ijk is the number of deaths reported in the SRS in the district i, j sex, and age group k
c_ij is the estimated number of deaths events in the district i (assuming all districts in the
same province have an equal coverage value) and sex j
For the calculation of maternal mortality, we then used a value of coverage for women, and
for the calculation of infant or toddler mortality, the coverage number of deaths of women
was used due to their having lower coverage and the coverage number of deaths of infants
and toddlers are believed to be lower than the coverage number deaths of adults.
Estimation
Indicators of mortality are estimated directly using the survey results and then adjusted for
death coverage. Indicators calculated are the following ratios: CDR, MMR, NMR, ENMR,
IMR, under-five mortality, and the mortality rate of children aged 1-4 years.
Estimates are calculated based on two scenarios, namely (1) without adjustment for death
coverage - unadjusted, and (2) adjusted for death coverage - adjusted.
Crude Death Rate (CDR)
CDR figures calculated by the formula :
Unadjusted
Adjusted
Maternal Mortality Rate (MMR)
MMR is calculated by the formula:
Indonesian SRS 2014 53
Unadjusted
Adjusted
with:
mi is the number of maternal deaths reported in SRS in the sub district i
c_i is an estimate of the coverage of reported incidence of death among women in the district
i (districts in the same province have an equal coverage value)
q_i is the number of births reported in SRS in the sub district i
Neonatal Mortality Rate (NMR)
NMR figures were calculated using the formula:
Unadjusted
Adjusted
with:
d_ ((0-28 days) i) is the number of infant deaths aged 0-28 days reported in SRS in the sub
district i
Early Neonatal Mortality Rate (ENMR)
ENMR figures calculated by the formula:
Unadjusted
Indonesian SRS 2014 54
Adjusted
with:
d ((0-7 days) i) is the number of infant deaths reported 0-7 days in the SRS in the sub district
i
Infant Mortality Rate (IMR)
IMR figures were calculated by the formula:
Unadjusted
Adjusted
with:
d _ ((<1 yr) i) is the number of infant deaths aged less than 1 year reported in the SRS in sub
district i
Under 5 Mortality Rate (U5MR)
U5MR figures were calculated using the formula:
Unadjusted
Adjusted
Indonesian SRS 2014 55
with:
ds ((0-4th) i) is the number of deaths of children aged 0-4 years reported in the SRS in sub
district i.
Child Mortality Rate (CMR)
CMR figures were calculated using the formula:
Unadjusted
Adjusted
with:
ds ((1-4th) i) is the number of deaths of children aged 1-4 years reported in the SRS in sub
district i.
Indonesian SRS 2014 56
Estimated results Results of the indicator estimates including the value of the standard error, 95% confidence
intervals and relative standard error (%) are shown in Table 1.
Tabel 1. Estimated Mortality Indicator Results, SRS 2014
Est SE 95% CI RSE
CDR Unadjusted 4.53 0.19 4.16 4.90 4.2%
Adjusted 7.48 0.31 6.87 8.09 4.1%
MMR Unadjusted 128.35 13.16 102.32 154.38 10.3%
Adjusted 244.64 26.20 192.79 296.49 10.7%
NMR Unadjusted 6.86 0.53 5.82 7.90 7.7%
Adjusted 12.88 1.10 10.70 15.07 8.5%
ENMR Unadjusted 5.59 0.44 4.71 6.46 7.9%
Adjusted 10.59 0.98 8.65 12.53 9.3%
IMR Unadjusted 9.95 0.73 8.50 11.40 7.3%
Adjusted 18.64 1.50 15.68 21.60 8.0%
U5MR Unadjusted 12.17 0.87 10.44 13.90 7.1%
Adjusted 22.93 1.85 19.26 26.60 8.1%
CMR Unadjusted 2.22 0.25 1.72 2.73 11.3% Adjusted 4.30 0.55 3.20 5.39 12.8%
Indonesian SRS 2014 57
APPENDIX 1
ESTIMATION OF THE TOTAL POPULATION IN 2014 BASED ON MINISTRY OF
HOME AFFAIRS (ADMINDUK) DATA IN SELECTED SUBDISTRICTS WITH
TRIMMED WEIGHT
Age Group Male Female Total
0-4 7,524,998 6,645,404 14,170,402 5-9 9,339,694 8,431,501 17,771,195 10-14 9,826,596 8,907,990 18,734,586 15-19 11,114,881 10,436,530 21,551,411 20-24 11,918,006 11,535,884 23,453,890 25-29 12,172,792 11,865,664 24,038,456 30-34 12,540,290 12,084,053 24,624,343
35-39 10,891,950 10,526,711 21,418,661 40-44 10,142,530 9,698,412 19,840,942 45-49 8,176,243 8,066,417 16,242,660 50-54 7,053,429 6,756,394 13,809,823 55-59 5,294,841 4,924,225 10,219,066 60-64 3,926,257 3,593,181 7,519,438 65+ 6,470,851 6,782,418 13,253,269
Total 126,393,358 120,254,784 246,648,142
Indonesian SRS 2014 58
APPENDIX 2
ESTIMATION OF THE TOTAL POPULATION IN 2014 BASED ON PROJECTION
RESULTS (BPS AND BAPPENAS)
Age group Male Female Total
0-4 12,301,392 11,785,386 24,086,778 5-9 11,857,284 11,252,246 23,109,530 10-14 11,448,373 10,911,854 22,360,227 15-19 11,237,841 10,786,863 22,024,704 20-24 10,768,431 10,583,932 21,352,363 25-29 10,398,169 10,318,093 20,716,262 30-34 10,150,247 10,280,665 20,430,912
35-39 9,802,553 9,784,546 19,587,099 40-44 9,054,191 8,950,497 18,004,688 45-49 7,949,128 7,918,231 15,867,359 50-54 6,650,671 6,663,076 13,313,747 55-59 5,319,575 5,198,516 10,518,091 60-64 3,804,761 3,714,074 7,518,835 65+ 5,972,572 7,301,619 13,274,191
Total 126,715,188 125,449,598 252,164,786
Indonesian SRS 2014 59
APPENDIX 3
ESTIMATION OF THE TOTAL POPULATION IN 2014 BASED ON SURVEY
RESULTS WITH SEX-AGE-SPECIFIC CELL WEIGHT ADJUSTMENT
Age group Male Female Total
0-4 12,352,988 11,710,785 24,063,773 5-9 12,683,173 11,990,420 24,673,593 10-14 12,353,039 11,702,632 24,055,671 15-19 11,242,861 10,913,607 22,156,468 20-24 10,473,241 10,634,551 21,107,792 25-29 11,260,873 11,352,327 22,613,200
30-34 10,538,536 10,504,231 21,042,767 35-39 9,890,464 9,745,526 19,635,990 40-44 8,815,564 8,719,190 17,534,754 45-49 7,449,203 7,450,030 14,899,233 50-54 6,213,368 6,054,348 12,267,716 55-59 4,660,893 4,303,449 8,964,342 60-64 3,100,533 3,328,979 6,429,512 65+ 5,680,450 7,039,523 12,719,973
Total 126,715,186 125,449,598 252,164,784
Indonesian SRS 2014 60
APPENDIX 4
LEVEL OF MORTALITY REPORTING COVERAGE OF 2010 POPULATION
CENSUS BY PROVINCE, METHOD AND SEX
Province BGB Preston-Cole
Male (%) Female (%) Male (%) Female (%)
Aceh
North Sumatera
West Sumatera
Riau
Jambi
South Sumatera
Bengkulu
Lampung
Bangka Belitung
Kepulauan Riau
Jakarta
West Java
Central Java
Yogyakarta
East Java
Banten
Bali
West Nusa Tenggara
East Nusa Tenggara
West Kalimantan
Central Kalimantan
South Kelimantan
East Kalimantan
North Sulawesi
Central Sulawesi
South Sulawesi
Southeast Sulawesi
Gorontalo
West Sukawesi
Maluku
North Maluku
West Papua
Papua
44
39
59
40
36
42
45
43
51
37
33
41
50
57
45
30
38
47
46
35
42
53
37
54
49
54
54
62
55
45
34
19
15
29
27
53
32
30
36
34
33
46
30
27
32
42
49
38
24
33
36
37
30
34
46
35
46
39
42
43
57
46
39
30
15
12
41
36
52
35
34
39
41
40
47
33
29
38
45
53
41
26
36
44
45
33
36
49
29
47
49
54
50
57
51
40
30
16
12
28
25
47
31
28
34
33
30
42
36
22
31
39
49
36
23
34
34
35
28
33
45
31
41
35
41
39
54
42
34
27
12
10
INDONESIA 44 37 41 35
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Tanda Tangan Responden : ................................................... Tanda Tangan Saksi : ...................................................
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RT/RW/KELURAHAN/DESA .............................................................................................................................................................................................
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5. NOMOR KASUS KEMATIAN.....................................................................................................................................................................................................................................................
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3. KECAMATAN.....................................................................................................................................................................................................................................................
4. KELURAHAN/DESA.....................................................................................................................................................................................................................................................
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1. PROVINSI......................................................................................................................................................................................................................................................
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1 2 3
HASIL KUNJUNGAN :
1. Lengkap 2. RT Tidak ada dirumah 3. Ditunda 4. Ditolak
5. Tidak lengkap 6. Responden tidak dapat dijumpai 7. Lainnya (sebutkan) ...................................................................
5. JUMLAH KUNJUNGAN4. TANGGAL ................................... ...................................
5. WAKTU ................................... ...................................
0 1
4. HASIL KUNJUNGANRENCANA KUNJUNGAN BERIKUTNYA :
3. HASIL KUNJUNGAN* 3. TAHUN 2
2. NAMA PEWAWANCARA ................................... ................................... ................................... 2. BULAN
1. TANGGAL ................................... ................................... ................................... 1. TANGGAL
1. KUNJUNGAN WAWANCARA
1.1 KETERANGAN KUNJUNGAN 1 2 3 4. KUNJUNGAN AKHIR
Propinsi Kab/Kota Kecamatan Kel/Desa No. Urut Kasus
KUESIONER AUTOPSI VERBAL 1UNTUK KEMATIAN NEONATAL UMUR 0 – 28 HARI
ID/NOMOR REFERENSI KONTROL
TIDAK TAMAT SD _____________________________________2
TAMAT SD ___________________________________________3
TAMAT SLTP ______________________________________4
TAMAT SLTA __________________________________________5
TAMAT PT __________________________________________6
meninggal?
RUMAH SAKIT _____________________________________
3
6
8
2
RUMAH __________________________________________
LAINNYA .................................................................
TIDAK TAHU ____________________________________
(sebutkan)
LAKI-LAKI ________________________________________
PEREMPUAN ____________________________________
304 Berapa umur Neonatal (almahum/ah) saat
KODE 98 → JIKA TANGGAL DAN BULAN TIDAK DIKETAHUI
6
→ JIKA TAHUN TIDAK DIKETAHUI
2
1
8
1
302 Apa jenis kelaminnya? 1
KODE 98 → JIKA TANGGAL DAN BULAN TIDAK DIKETAHUI
LAKI-LAKI ________________________________________
PEREMPUAN ____________________________________2
3. KETERANGAN NEONATAL (ALMARHUM/AH) DAN TANGGAL/TEMPAT KEMATIAN
301
303
BULAN
Di mana Neonatal (Almarhum/ah) meninggal?
KODE 9998
305 Kapan Neonatal (Almarhum/ah) meninggal?
KODE 9998
TIDAK _______________________________________________
207
Siapa nama Neonatal (Almarhum/ah )?
Kapan Neonatal (Almaruhum/ah) lahir?
................................................................................................
→ JIKA TAHUN TIDAK DIKETAHUI
306 1
205 Apakah pendidikan terakhir Bapak/Ibu/Sdr/i? TIDAK SEKOLAH _____________________________________1
2
1
(sebutkan)
SAUDARA ___________________________________________
HUBUNGAN LAINNYA ...................................................
TIDAK ADA HUBUNGAN _____________________________
Apakah Bapak/Ibu/Sdr/i tinggal dengan Neonatal
(Almarhum/ah) pada saat menjelang kematiannya?
YA _______________________________________________
JAM _________________________________
HARI __________________________________
1
2
TANGGAL
BULAN
4
JAM
PERTANYAAN KATEGORI KODE LANJUT KENO.
2. KETERANGAN RESPONDEN
201
Umur Responden
Jenis Kelamin Responden204
2
AYAH _____________________________________________
IBU ________________________________________________
................................................................................................202 Nama Responden
Catatan waktu awal wawancara
Neonatal (Almahum/ah)?
MENIT
UMUR DALAM TAHUN203
FASILITAS KESEHATAN LAINNYA _________________________
TAHUN
206 Apakah hubungan Bapak/Ibu/Sdr/i dengan
TANGGAL
TAHUN
PERTANYAAN KATEGORI KODE LANJUT KENO.
.......................................................................................................................................................................................................
4.
1.
2.
3.
4.
.......................................................................................................................................................................................................
.......................................................................................................................................................................................................
Dapatkah Bapak/Ibu/Sdr menceritakan tentang riwayat penyakit/kejadian yang menyebabkan
5. RIWAYAT KEHAMILAN IBU DARI NEONATAL (ALMARHUM/AH)
402
Saya ingin menanyakan tentang keadaan penyakit yang pernah diderita Almarhum/ah sebelum saat meninggalnya,
kejadian cedera atau kecelakaan yang pernah dialami, dan tanda dan gejala yang dialami oleh Almarhum/ah saat
sakitnya. Beberapa pertanyaan mungkin tidak berhubungan langsung dengan penyebab kematian Almarhum/ah. Kami
mengharap kesabaran anda untuk menjawab pertanyaan. Jawaban anda akan membantu kami untuk mendapatkan
kejelasan tanda dan gejala yang pernah dialami oleh Almarhum/ah saat sakitnya.
Penyebab kematian berdasarkan responden : ...............................................................................................................
kali ibu melahirkan, termasuk yang lahir mati.
506
4. PENJELASAN RESPONDEN TENTANG PENYAKIT/KEJADIAN YANG MENYEBABKAN KEMATIAN
401
8
(sebutkan) ...............................................................................................................
Mohon katakan jika Almarhum/ah mengalami penyakit seperti berikut :
TIDAK TAHU ______________________________9 8
TIDAK TAHU ______________________________9 8
BULAN ________________________________________________
KENCING MANIS/DIABETES
EPILEPSI/AYAN
PENYAKIT LAINNYA
504 Berapa minggu sebelum waktu yang seharusnya?
8
503
2seharusnya?
Apakah ibu melahirkan sebelum waktu yang 1
Y
Selama kehamilan apakah ibu mengalami
2 85.
8
2. 1 2
502 Berapa usia kehamilan saat Neonatal (Almarhum/ah)
1 2
JML KELAHIRAN TMSK LAHIR MATI ________501 Sebelum kelahiran Neonatal (Almarhum/ah), berapa
1.
505
10.
Perdarahan pervagina?
Keluar cairan vagina bau?
Wajah bengkak?3. 1 2
1 2 8
PERDARAHAN PER VAGINA
1 2 8
T TT
Tekanan darah tinggi?
Penyakit jantung?
Kencing manis / Diabetes?
Epilepsi/ayan?
8. 1 2
1.
2.
3.
5. 1
3.
mengalami penyakit seperti di bawah ini? Y T TT
Sakit kepala?
Pandangan kabur?
Kejang?
Demam?
Sakit perut hebat ? (bukan sakit persalinan)
4.
5.
6.
7.
8.
9.
SAKIT KEPALA
5. 1 2
2 81
Neonatal (Almarhum/ah) meninggal? ..................................................................................................................................
.......................................................................................................................................................................................................
.......................................................................................................................................................................................................
penyakit seperti di bawah ini?
TEKANAN DARAH TINGGI
PENYAKIT JANTUNG
dilahirkan?
YA _______________________________________________
TIDAK ___________________________________________
89
TIDAK TAHU _______________________________________
MINGGU ________________________________________________
TIDAK TAHU ______________________________
2
8
2. 1 2 8
1. 1
7. 1 2 8
6. 1 2 8
(sebutkan) ...............................................................................................................
Pucat dan sesak nafas
Penyakit lainnya?
4.
KELUAR CAIRAN VAGINA BAU
WAJAH BENGKAK
Selama 3 bulan terakhir kehamilan, apakah ibu
8
9.
1 82
KEJANG
DEMAM
SAKIT PERUT HEBAT
(BUKAN SAKIT PERSALINAN)
PUCAT DAN NAFAS CEPAT
PENYAKIT LAIN
8
8
1 2 8
505
505
10.
Apakah ada penyakit lainnya?
PANDANGAN KABUR
PERTANYAAN KATEGORI KODE LANJUT KENO.
604 1
TIDAK TAHU ______________________________________
Urutan kelahiran keberapa Neonatal ini dari
saudara kembarnya?
PERTAMA ________________________________________
KEDUA __________________________________________2
508 1
603
507 Apakah Neonatal (Almarhum/ah) lahir tunggal
602
6. RIWAYAT PERSALINAN NEONATAL (ALMARHUM/AH)
601 01
02
03
04
05
06
96
98
(sebutkan)
TIDAK TAHU _____________________________________
2
3
Kapankah air ketuban pecah?
LAINNYA ...............................................................................................................
SEBELUM PERSALINAN DIMULAI ___________________
RUMAH SAKIT ___________________________________
PUSKESMAS/PUSTU _______________________________
RUMAH BERSALIN ________________________________
POLINDES ______________________________________
PRAKTEK BIDAN ____________________________________
RUMAH ______________________________________
Di manakah Neonatal (Almarhum/ah) dilahirkan?
Siapakah yang menolong persalinan?
608 Apakah penolong persalinan mendengarkan 1
607 1
2
Sejak kapankah bayi berhenti bergerak sewaktu
di dalam kandungan?
2
8
8
606 Apakah bayi sudah tidak bergerak sewaktu 1
605 1
2
Apakah air ketubannya berbau?
di dalam kandungan?
SEBELUM PERSALINAN DIMULAI _______________________
SAAT PERSALINAN __________________________________
TIDAK TAHU ______________________________________
YA _______________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
2
8TIDAK TAHU _______________________________________
denyut jantung janin selama proses persalinan? TIDAK ___________________________________________
6
8
3
8
Berapa jam setelah ketuban pecah bayi dilahirkan?
2
1
8
4
5
DOKTER ___________________________________________
8
2
1
≤ 12 JAM __________________________________________
8
8
LAINNYA .................................................................
> 12 - 24 JAM __________________________________________
> 24 JAM ____________________________________________
TIDAK TAHU ________________________________________
YA _______________________________________________
TIDAK ___________________________________________
1
(sebutkan)
DUKUN BERSALIN _______________________________________________
KELUARGA _____________________________________________
TIDAK TAHU ____________________________________________
3
TIDAK TAHU ______________________________________
SEWAKTU PERSALINAN ___________________________
KETIGA ATAU LEBIH _____________________________
TIDAK TAHU _________________________________
3
atau kembar? KEMBAR _________________________________________
KEMBAR TIGA ATAU LEBIH ________________________
2
TUNGGAL ________________________________________
BIDAN ______________________________________________________
PERAWAT _________________________________________________
601
601
608
608
610
610
PERTANYAAN KATEGORI KODE LANJUT KENO.
610 Apakah ada perdarahan yang banyak saat 1
2
8
609 1
2
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
Apakah denyut jantung janin terdengar?
8
614 1
2
612 1
611
2
Apakah persalinan normal?
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
KURANG DARI 12 JAM _______________________________
12 - 23 JAM ________________________________________
24 JAM ATAU LEBIH __________________________________
TIDAK TAHU _________________________________________
persalinan dimulai?
Apakah ibu mengalami demam pada saat
persalinan dimulai?
8
3
1
2
8
1
2
8
613
Berapa lama proses persalinan?
(dari pertama his melahirkan)
7. KONDISI NEONATAL (ALMARHUM/AH) SESAAT SETELAH LAHIR
701 Bagaimanakah ukuran Neonatal (Almarhum/ah) 1
8
616
4
6
(sebutkan)
2
3
615 Bagian tubuh Neonatal manakah yang keluar 1
6
8
Apakah tali pusat keluar terlebih dahulu sebelum 1
2
8
(sebutkan)
KAKI __________________________________________________
TANGAN ______________________________________________
TIDAK TAHU _____________________________________________
SANGAT KECIL ____________________________________________
TIDAK TAHU _______________________________________
terlebih dahulu?
Neonatal (Almarhum/ah) lahir?
YA _______________________________________________
703
702 Apakah Neonatal (Almarhum/ah)
9
4
8
2
3
89
1
2
8
LEBIH KECIL DARI NORMAL _________________________
NORMAL ____________________________________________
LEBIH BESAR DARI NORMAL ____________________________
TIDAK TAHU ____________________________________________
MENGGAMBARKAN UMUR KEHAMILAN
Neonatal (Almarhum/ah) lahir?
TIDAK TAHU _______________________________________
Jenis persalinan? FORCEPS/VACUM ________________________________________
OPERASI SESAR ____________________________________
TIDAK ___________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
lahir kurang bulan?
615
615
LAINNYA .................................................................
LAINNYA .................................................................
704
704
1
2
BULAN ________________________________________
MINGGU ____________________________________
TIDAK TAHU _________________________________
KEPALA _____________________________________________
BOKONG ___________________________________________
saat lahir?
Pada usia kehamilan berapakah (bulan/minggu)
PERTANYAAN KATEGORI KODE LANJUT KENO.
JIKA SEMUA JAWABAN 713, 715, 716 → "TIDAK",
PERIKSA JAWABAN DARI PERTANYAAN NO. 713, 715, 716, JIKA JAWABAN 713, 715, 716 → "SELAIN TIDAK"
704 Berapakah berat badan lahir Neonatal GRAM ________________________________
706 ...............................................................................................
709
708 Jika "YA" sebutkan dibagian tubuh mana tanda
705 Apakah tali pusat diberi sesuatu setelah 1
2
8
...............................................................................................
...............................................................................................
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
dilahirkan?
Jika diberikan sesuatu, sebutkan!
Apakah terdapat tanda cedera atau patah tulang
ketika Neonatal (Almarhum/ah) dilahirkan?
710
707
1
2
2
8
cedera atau patah tulang tersebut!
Apakah ditemukan tanda kelumpuhan?
1
2
8
1
cacat bawaan saat lahir?
712 1
4
6
2
3
Neonatal (Almarhum/ah)?
Bagaimana warna kulit Neonatal (Almarhum/ah)
waktu dilahirkan?
711 1
8
713 Apakah Neonatal (Almarhum/ah) sempat bernafas
setelah dilahirkan walaupun sebentar?
8
(sebutkan)
8
YA _______________________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
LAINNYA .................................................................
TIDAK TAHU __________________________________________
TIDAK TAHU _______________________________________
NORMAL ___________________________________________
PUCAT ____________________________________________
BIRU ______________________________________________
Kecacatan seperti apakah yang dimiliki
3
bantuan pernafasan?
717
716 Apakah Neonatal (Almarhum/ah) bergerak
sewaktu dilahirkan walaupun sebentar dan lemah?
715
714
1
2
8
1
2
8
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
Apakah Neonatal (Almarhum/ah) menangis
1
2
Apakah Neonatal (Almarhum/ah) mendapatkan
TIDAK ___________________________________________
8
1
2
8TIDAK TAHU _______________________________________
9 9 9
8
Apakah Neonatal (Almarhum/ah) memiliki
709
712
712
BENJOLAN/CACAT DI TULANG BELAKANG _______________
KEPALA SANGAT BESAR _________________________________
KEPALA SANGAT KECIL ______________________________
BIBIR DAN ATAU LANGIT-LANGIT SUMBING _______________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
709
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ____________________________
707
707TIDAK TAHU _______________________________________
sewaktu dilahirkan walaupun sebentar dan lemah?
2
801
(Almarhum/ah)?
PERTANYAAN KATEGORI KODE LANJUT KENO.
Jenis cedera apa yang menyebabkan Neonatal
717 Jika Neonatal (Almarhum/ah) tidak menangis, tidak
bernafas dan tidak bergerak, apakah Neonatal
1
2
YA _______________________________________________
8
TIDAK TAHU _________________________________________
802 01
02
03
04
05
06
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
8. RIWAYAT CEDERA
801
718 1
2
8
1
2
8
Apakah Neonatal (Almarhum/ah) mengalami
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
Apakah kulit Neonatal (Almarhum/ah) mengalami
maserasi, menunjukkan tanda pembusukan?
cedera yang menyebabkan kematiannya? 804
804
803 1
2
8
1
2
8
YA _______________________________________________
TIDAK ___________________________________________
LAINNYA .................................................................
Sebutkan jenis binatang/serangga tersebut? ANJING ___________________________________________________
ULAR ________________________________________________
SERANGGA ____________________________________________
binatang/serangga sehingga meninggal?
903
9 89
902
8
1
2
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
(Almarhum/ah) lahir mulai menyusu atau
menghisap susu botol?
Apakah Neonatal (Almarhum/ah) berhenti
TIDAK TAHU ______________________________
96
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
TIDAK ___________________________________________
KEKERASAN ________________________________________
TIDAK TAHU
LAINNYA .................................................................
TIDAK TAHU _______________________________________
98
8
9. RIWAYAT PENYAKIT SEBELUM NEONATAL (ALMARHUM/AH) MENINGGAL
(Almarhum/ah) lahir mati (lahir sudah mati)?
Apakah cedera tersebut dilakukan oleh
(sebutkan)
901
901
orang lain dengan sengaja?
Apakah Neonatal (Almarhum/ah) digigit
JIKA JAWABAN 717 → "TIDAK"
PERIKSA JAWABAN DARI PERTANYAAN 717 UNTUK NEONATAL YANG LAHIR MATI : JIKA JAWABAN 717 → "YA" 1001
JAM 1
2
Berapa lama (jam/hari) setelah Neonatal
801
HARI
905
(Almarhum/ah) meninggal?
KECELAKAAN LALU LINTAS ________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
(SEBUTKAN)
901
3
6
805 1
2
1
2
8
804
menyusu atau menghisap susu botol?
Apakah Neonatal (Almarhum/ah) dapat
menyusu atau menghisap susu botol?
905
905
905
JATUH _________________________________________
TENGGELAM ______________________________________
KERACUNAN _____________________________________
KEBAKARAN ______________________________________
PERTANYAAN KATEGORI KODE LANJUT KENO.
904
1
9
908
907 Berapa lama (hari) setelah dilahirkan Neonatal
1Apakah Neonatal (Almarhum/ah) mengalami kaku
906
2
8
1
2
8
905
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
9TIDAK TAHU ____________________________________
HARI ____________________________________
mengalami kejang?
YA _______________________________________________
8
911
910 Berapa lama (hari) setelah dilahirkan Neonatal
1
9 8
YA _______________________________________________
909
2
8
1
2
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
dan badan melengkung ke belakang?
Apakah ubun-ubun Neonatal (Almarhum/ah)
menonjol?
(Almarhum/ah) mengalami ubun-ubun menonjol
Apakah Neonatal (Almarhum/ah) mengalami
913 1
2
8
8
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
912 Berapa lama (hari) setelah dilahirkan Neonatal
2
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
HARI _______________________________________
TIDAK TAHU ____________________________________9
penurunan kesadaran atau tidak memberikan
reaksi?
(Almarhum/ah) mengalami penurunan kesadaran
atau tidak memberikan reaksi?
Apakah Neonatal (Almarhum/ah) mengalami
demam?
915 Apakah Neonatal (Almarhum/ah) terasa dingin
9
914 Berapa lama (hari) setelah dilahirkan Neonatal
1
2
8
8
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
HARI ____________________________________
TIDAK TAHU ____________________________________
ketika disentuh?
(Almarhum/ah) mengalami demam?
917
9
916 Berapa lama (hari) setelah dilahirkan Neonatal
1
2
8
8
Apakah Neonatal (Almarhum/ah) pernah YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
mengalami batuk?
HARI ____________________________________
TIDAK TAHU ____________________________________(Almarhum/ah) terasa dingin ketika disentuh?
9
918 Berapa lama (hari) setelah dilahirkan Neonatal
8
HARI ____________________________________
TIDAK TAHU ____________________________________mulai mengalami batuk?
911
911
913
913
915
915
917
917
919
919
HARI ____________________________________
TIDAK TAHU ____________________________________
Apakah Neonatal (Almarhum/ah)
8
Berapa lama (hari) setelah Neonatal (Almarhum/ah)
lahir berhenti menyusu atau menghisap botol?
Apakah Neonatal (Almarhum/ah)
mendapatkan ASI eksklusif?
TIDAK TAHU ____________________________________
HARI _______________________________________
(Almarhum/ah) mulai mengalami kejang?
tersebut?
908
908
PERTANYAAN KATEGORI KODE LANJUT KENO.
HARI ____________________________________
TIDAK TAHU ____________________________________
Ketika diare paling parah, berapa kali
921
921
926
1
2
8
Apakah Neonatal (Almarhum/ah) pernah YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
921
9
920
8
1
2
8
Apakah Neonatal (Almarhum/ah) pernah YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
919
HARI ____________________________________
TIDAK TAHU ____________________________________
926
925
Apakah Neontal (Almarhum/ah) pernah
mengalami diare?
924
(Mengorok/mendengkur dan mengi)
923
(Almarhum/ah) mulai mengalami sulit bernafas? 9
922
1
2
8
1
2
8
1
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________Apakah saat bernafas, cuping hidung Neonatal
Apakah otot dinding dada bagian bawah Neonatal
(Almarhum/ah) tertarik ke dalam ketika bernafas?
Apakah nafas Neonatal (Almarhum/ah) berbunyi
Berapa lama (hari) setelah dilahirkan Neonatal
9
927 Berapa lama (hari) setelah dilahirkan Neonatal
(Almarhum/ah) mengalami diare?
buang air besar dalam sehari?
HARI ____________________________________
TIDAK TAHU ____________________________________
926
8
2TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
(Almarhum/ah) terlihat kembang kempis?
8
930
930
929 1
2
8
Apakah ada darah dalam tinja?
9
928
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
9
931
930 Apakah Neonatal (Almarhum/ah) pernah
8
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
mengalami muntah?
Berapa lama (hari) setelah dilahirkan Neonatal
(Almarhum/ah) mulai mengalami muntah?
HARI ____________________________________
TIDAK TAHU ____________________________________
2
8
933
933
933 Apakah perut Neonatal (Almarhum/ah)
9
932 Ketika muntah paling berat, berapa kali
2
8
8
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
muntah dalam sehari?
terlihat/teraba menggembung dan kencang?
JUMLAH ____________________________________
1
935
935
TIDAK TAHU ____________________________________
(Almarhum/ah) terlihat/teraba menggembung 9
934 Berapa lama (hari) setelah lahir perut Neonatal
dan kencang?
HARI ____________________________________
TIDAK TAHU ____________________________________
1
8
8
HARI ____________________________________
TIDAK TAHU ____________________________________
mengalami nafas cepat?
(Almarhum/ah) mulai mengalami nafas cepat?
Berapa lama (hari) setelah dilahirkan Neonatal
mengalami sulit bernafas?
8
8
1
2
* TIRUKAN SUARANYA
PERTANYAAN KATEGORI KODE LANJUT KENO.
pengobatan untuk penyakit terakhirnya sebelum
...............................................................................................
...............................................................................................
...............................................................................................
diberikan kepada Neonatal (Almarhum/ah) untuk
SALIN RESEP/CATATAN KWITANSI JIKA ADA
meninggal?
Bagaimana keadaan kesehatan Ibu sekarang?
935 Apakah pada tali pusat Neonatal (Almarhum/ah) 1
2
8
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
terdapat tanda kemerahan atau keluar cairan
yang berbau?
936 1
2
8
1
Apakah pada kulit Neonatal (alamrhum/ah)
Apakah telapak tangan/kaki Neonatal
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
terdapat bintik-bintik merah yang menonjol?
(Almarhum/ah) tampak kuning/pucat?1001
9
939
938
2
8
9 8
937
8
Berapa lama (hari) setelah lahir telapak tangan/kaki
Neonatal (Almarhum/ah) tampak kuning/pucat?
Berapa lama (hari) telapak tangan/kaki
Neonatal (Almarhum/ah) tampak kuning/pucat?
HARI ____________________________________
TIDAK TAHU ____________________________________
HARI ____________________________________
TIDAK TAHU ____________________________________
1001
1003
1002 1
2
8
1
10. KESEHATAN IBU DAN FAKTOR LAINNYA
1001 Berapa umur ibu ketika Neonatal
Apakah Ibu mendapatkan suntikan TT?
Apakah Ibu memeriksakan kehamilannya?
(Almarhum/ah) meninggal?9 8
1005
TIDAK TAHU ____________________________________
TAHUN ____________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
11. PENGOBATAN DAN PELAYANAN KESEHATAN PADA EPISODE SAKIT TERAKHIR
3
1005 1
2
1004
2
8
Berapa kali Ibu mendapatkan suntikan TT?
9 8
8
MENINGGAL __________________________________________
TIDAK TAHU _________________________________________
1005
JUMLAH ____________________________________
TIDAK TAHU ____________________________________
SEHAT __________________________________________________
SAKIT _____________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
penyakit yang menyebabkannya meninggal? ...............................................................................................
...............................................................................................
1102 Sebutkan jenis obat (pengobatan) apa saja yang
1101 Apakah Neonatal (Almarhum/ah) mendapat 1
2
8
...............................................................................................
...............................................................................................
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
1201
1201
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
PERTANYAAN KATEGORI KODE LANJUT KENO.
1203
1203
1301
1301
1306
meninggal?
tentang penyebab kematiannya? ...............................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
1.
2.
3.
Rumah?
Pengobatan Tradisional?
Puskesmas?
RUMAH
PENGOBATAN TRADISIONAL
PUSKESMAS
Klinik Swasta?
1103 Dimana saja Neonatal (Almarhum/ah) mendapatkan
3.
1 2 8
8
2.
1 2 8
pengobatan untuk sakit yang menyebabkannya Y T TT
1.
1 2
6.
1 2 85.
1 2 84.
1 2 84.
5.
6.
RS Pemerintah?
2 8
8
7.
1 2 87.
8.Apotik, Toko Obat, Warung?
Tempat Lain?
APOTIK, TOKO OBAT, WARUNG
TEMPAT LAIN
(sebutkan) ...............................................................................................
JUMLAH PERIKSA ____________________________________
TIDAK TAHU ____________________________________oleh petugas kesehatan?
1106 Apa yang dijelaskan oleh petugas kesehatan
1105 1
2
8
...............................................................................................
(Almarhum/ah) pernah mendapatkan pelayanan 9
1104 Sebelum meninggal, berapa kali Neonatal
Apakah petugas kesehatan menjelaskan
penyakit/penyebab kematiannya?
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
12. DATA YANG TERTULIS DARI SURAT KETERANGAN KEMATIAN
1201 Apakah Neonatal (Almarhum/ah) mempunyai 1
2
8
Surat Keterangan Kematian?
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
1
DARI SURAT KETERANGAN KEMATIAN
YA _______________________________________________
1202 (Bolehkan saya melihat akte kematian tersebut?)
SALIN TANGGAL, BULAN, DAN TAHUN KEMATIAN
1203 Apakah Neonatal (Almarhum/ah) memiliki akte
TANGGAL BULAN TAHUN
1303 SURAT IZIN PENGUBURAN (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM SURAT TERSEBUT)
..........................................................................................................................................................................................................................................
1204 (Bolehkan saya melihat akte kematian tersebut?)
SALIN TANGGAL, BULAN, DAN TAHUN
1302 SALINLAH SEMUA KETERANGAN MEDIS YANG MENDUKUNG DARI DUA PELAYANAN KESEHATAN TERAKHIR (JIKA LEBIH DARI
DUA) DAN CATAT TANGGAL KETERANGAN MEDIS TERSEBUT (CATAT INFORMASI MENGENAI IBU DAN NEONATAL)
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
13. KETERANGAN PENDUKUNG DARI CATATAN KESEHATAN LAINNYA
TAHUN
TIDAK ___________________________________________
1301 Apakah ada keterangan kesehatan pendukung
DIKELUARKANNYA AKTE KEMATIAN?
TANGGAL BULAN
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
Kematian yang dikeluarkan oleh Kantor Dinas
Kependudukan dan Catatan Sipil?
lainnya?
2
1
2
1201
1201
RS Swasta?
RS PEMERINTAH
KLINIK SWASTA
RS SWASTA
8.
1
PERTANYAAN KATEGORI KODE LANJUT KENO.
..................................................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
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..........................................................................................................................................................................................................................................
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..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
(ALMARHUM/AH)) ..........................................................................................................................................................................................................................................
CATATAN PEWAWANCARA
DIISI SETELAH WAWANCARA SELESAI
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
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1305 BUKU KIA/KMS (JIKA ADA, SALINLAH INFORMASI YANG BERHUBUNGAN DENGAN KESEHATAN IBU DAN NEONATAL
..........................................................................................................................................................................................................................................
1304
HASIL VISUM TERSEBUT) ..........................................................................................................................................................................................................................................
1306 CATATAN WAKTU AKHIR WAWANCARA
..........................................................................................................................................................................................................................................
JAM
MENIT
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
HASIL PEMERIKSAAN VISUM/AUTOPSY FORENSIK (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM
..........................................................................................................................................................................................................................................
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14. RESUME DAN DIAGNOSA (Dibuat oleh Dokter)
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
NAMA DOKTER : ..........................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
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RESUME AUTOPSI VERBAL : ..........................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
Propinsi Kab/Kota Kecamatan Kel/Desa No. Urut Kasus
ID/NOMOR REFERENSI KONTROL
A. KEMATIAN UMUR 7 HARI KE ATAS SELANG WAKTU MULAI TERJADINYA PENYAKIT SAMPAI MENINGGAL
I. PENYEBAB KEMATIAN MENURUT DOKTER PUSKESMAS THN BLN HARI JAM ICD -10
disebabkan oleh
c.
....................................................................................................................................................................
disebabkan oleh
b.
....................................................................................................................................................................
a.
....................................................................................................................................................................
disebabkan oleh
d.
....................................................................................................................................................................
....................................................................................................................................................................
II. PENYAKIT/KONDISI LAIN YANG BERKONTRIBUSI
NAMUN TIDAK BERHUBUNGAN DENGAN I a-d
....................................................................................................................................................................
B. KEMATIAN UMUR 0 - 6 HARI SELANG WAKTU MULAI TERJADINYA PENYAKIT SAMPAI MENINGGAL
a. PENYEBAB UTAMA BAYI THN BLN HARI JAM ICD -10
....................................................................................................................................................................
NAMA DOKTER :.....................................................................................................TANDA TANGAN DOKTER : .....................................................................................................
d. PENYEBAB LAIN IBU
....................................................................................................................................................................
TANGGAL DIAGNOSIS :.....................................................................................................
c. PENYEBAB UTAMA IBU
....................................................................................................................................................................
b. PENYEBAB LAIN BAYI
....................................................................................................................................................................
( )
RESPONDEN SETUJU DIWAWANCARAI : 1. SETUJU DIWAWANCARAI
2. MENOLAK DIWAWANCARA → AKHIRI
Nama Responden : ( ) Nama Saksi :
NO. TELEPON / HP ..............................................................................................................................................................................
INFORMED CONSENT
Selamat pagi/siang/sore/malam, Nama saya................................... dan saya bekerja di........................................ Kami sedang mengumpulkan data tentang penyebab
kematian di daerah ini. Kami sangat senang sekali apabila Bapak/Ibu dapat ikut berpartisipasi dalam kegiatan ini. Kami akan bertanya mengenai keadaan yang
menyebabkan kematian. Informasi apapun yang Bapak/Ibu berikan akan kami simpan dan dirahasiakan. Identitas Bapak/Ibu (responden) maupun
almarhum/ah.............................. tidak akan kami beri tahu kepada siapapun. Partisipasi untuk kegiatan ini adalah sukarela dan Bapak/Ibu dapat memilih untuk
bersedia menjawab sebagian pertanyaan atau tidak bersedia menjawab semuanya. Bapak/Ibu dapat menghentikan wawancara kapan saja tanpa ada konsekuensi.
Kami berharap Bapak/Ibu dapat ikut berpartisipasi dalam kegiatan ini, karena hal ini akan membantu pemerintah untuk meningkatkan pelayanan kesehatan
khususnya di daerah ini. Sekarang ini apakah Bapak/Ibu ingin bertanya mengenai tujuan dan isi dari wawancara ini? Bolehkah saya memulai wawancara ini
sekarang?
Tanda Tangan Responden : ................................................... Tanda Tangan Saksi : ...................................................
10. ALAMAT LENGKAP ALMARHUM/AH ............................................................................................................................................................................................................................................................
RT/RW/KELURAHAN/DESA .............................................................................................................................................................................................
............................................................................................................................................................................................................................................................
7. NAMA KEPALA RUMAH TANGGA.....................................................................................................................................................................................................................................................
8. NAMA RESPONDEN.....................................................................................................................................................................................................................................................
9. STATUS KEPENDUDUKAN ALMARHUM/AH 1. Penduduk 2. Bukan Penduduk
5. NOMOR KASUS KEMATIAN.....................................................................................................................................................................................................................................................
6. NAMA ALMARHUM/AH.....................................................................................................................................................................................................................................................
3. KECAMATAN.....................................................................................................................................................................................................................................................
4. KELURAHAN/DESA.....................................................................................................................................................................................................................................................
1.3 DATA DEMOGRAFI
1. PROVINSI......................................................................................................................................................................................................................................................
2. KABUPATEN.....................................................................................................................................................................................................................................................
2. TANGGAL ...................................
1. NAMA ...................................
1.2 KETERANGAN PENGAWAS/EDITOR
PENGAWAS/EDITOR EDITOR PUSAT KODE PENGENTRI
1 2 3
HASIL KUNJUNGAN :
1. Lengkap 2. RT Tidak ada dirumah 3. Ditunda 4. Ditolak
5. Tidak lengkap 6. Responden tidak dapat dijumpai 7. Lainnya (sebutkan) ...................................................................
5. JUMLAH KUNJUNGAN4. TANGGAL ................................... ...................................
5. WAKTU ................................... ...................................
0 1
4. HASIL KUNJUNGANRENCANA KUNJUNGAN BERIKUTNYA :
3. HASIL KUNJUNGAN* 3. TAHUN 2
2. NAMA PEWAWANCARA ................................... ................................... ................................... 2. BULAN
1. TANGGAL ................................... ................................... ................................... 1. TANGGAL
1. KUNJUNGAN WAWANCARA
1.1 KETERANGAN KUNJUNGAN 1 2 3 4. KUNJUNGAN AKHIR
Propinsi Kab/Kota Kecamatan Kel/Desa No. Urut Kasus
KUESIONER AUTOPSI VERBAL 2UNTUK KEMATIAN ANAK UMUR 29 HARI - 14 TAHUN
ID/NOMOR REFERENSI KONTROL
205 Apakah pendidikan terakhir Bapak/Ibu/Sdr/i? TIDAK SEKOLAH _____________________________________1
TIDAK TAMAT SD _____________________________________2
TAMAT SD ___________________________________________3
TAMAT SLTP ______________________________________4
TAMAT SLTA __________________________________________5
TAMAT PT __________________________________________6
SUAMI/ISTRI ___________________________________________3
NO.
3. KETERANGAN ANAK (ALMARHUM/AH) DAN TANGGAL/TEMPAT KEMATIAN
2
1Apakah Pendidikan tertinggi Anak (Almarhum/ah)?
KODE 98 → JIKA TANGGAL DAN BULAN TIDAK DIKETAHUI BULAN
KODE 9998 → JIKA TAHUN TIDAK DIKETAHUI
4
TIDAK TAMAT SD ___________________________________
TAMAT SD ________________________________________
TAMAT SMP ________________________________________
Apakah Anak (Almarhum/ah) bekerja?
3
8TIDAK TAHU ______________________________________
1
(Almahum/ah)?IBU ________________________________________________2
SAUDARA ___________________________________________4
HUBUNGAN LAINNYA ...................................................6
204
206
207
301
302
303
304
305
306
Berapa umur Anak (Almarhum/ah) saat meninggal?
JIKA Anak UMUR < 5 TAHUN, TULIS DALAM BULAN
PERTANYAAN KATEGORI KODE LANJUT KE
2. KETERANGAN RESPONDEN
MENIT
202 Nama Responden ................................................................................................
203 Umur Responden UMUR DALAM TAHUN
201 Catatan waktu awal wawancara JAM
Jenis Kelamin Responden LAKI-LAKI ________________________________________1
PEREMPUAN ____________________________________2
2
UMUR DALAM BULAN _________________________________1
UMUR DALAM TAHUN __________________________________2
YA _______________________________________________
TIDAK ___________________________________________
TIDAK SEKOLAH ___________________________________
Apakah hubungan Bapak/Ibu/Sdr/I dengan Anak AYAH _____________________________________________1
(sebutkan)
TIDAK ADA HUBUNGAN _____________________________8
Apakah Bapak/Ibu/Sdr/I tinggal dengan Anak YA _______________________________________________1
TAHUN
Apa jenis kelaminnya? LAKI-LAKI ________________________________________1
PEREMPUAN ____________________________________2
Kapan Anak (Almaruhum/ah) lahir? TANGGAL
(Almarhum/ah) pada saat menjelang kematiannya? TIDAK _______________________________________________2
Siapa nama Anak (Almarhum/ah)? ................................................................................................
NO. PERTANYAAN KATEGORI KODE LANJUT KE
(untuk umur > 10 tahun)
Saya ingin menanyakan tentang keadaan penyakit yang pernah diderita Almarhum/ah sebelum saat meninggalnya,
kejadian cedera atau kecelakaan yang pernah dialami, dan tanda dan gejala yang dialami oleh Almarhum/ah saat
sakitnya. Beberapa pertanyaan mungkin tidak berhubungan langsung dengan penyebab kematian Almarhum/ah. Kami
mengharap kesabaran anda untuk menjawab pertanyaan. Jawaban anda akan membantu kami untuk mendapatkan
kejelasan tanda dan gejala yang pernah dialami oleh Almarhum/ah saat sakitnya.
(Almarhum/ah) meninggal? ..................................................................................................................................
2
8
Mohon katakan jika Almarhum/ah mengalami penyakit seperti berikut :
8
1
Apakah Anak (Almarhum/ah) menderita asma?
Apakah Anak (Almarhum/ah) menderita kencing
.......................................................................................................................................................................................................
.......................................................................................................................................................................................................
.......................................................................................................................................................................................................
.......................................................................................................................................................................................................
.......................................................................................................................................................................................................
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
2
402
501
502
503
504
5. RIWAYAT PENYAKIT/MEDIS ANAK (ALMARHUM/AH) SEBELUMNYA
Penyebab kematian berdasarkan responden : ...............................................................................................................
1
Di mana Anak (Almarhum/ah) meninggal?
2
3
FASILITAS KESEHATAN LAINNYA _________________________
RUMAH __________________________________________
LAINNYA .................................................................
TIDAK TAHU ____________________________________
(sebutkan)
1
KODE 98 → JIKA TANGGAL DAN BULAN TIDAK DIKETAHUI
KODE 9998 → JIKA TAHUN TIDAK DIKETAHUI
BULAN
TAHUN
RUMAH SAKIT _____________________________________
8
Kapan Anak (Almarhum/ah) meninggal?
4
5
307
308
2
3
Status perkawinan Anak (Almarhum/ah)?
MENIKAH ____________________________________
CERAI HIDUP ____________________________________
CERAI MATI ____________________________________
HIDUP BERPISAH ____________________________________
TIDAK TAHU ____________________________________
TANGGAL
BELUM MENIKAH ____________________________________
4. PENJELASAN RESPONDEN TENTANG PENYAKIT/KEJADIAN YANG MENYEBABKAN KEMATIAN
Dapatkah Bapak/Ibu/Sdr menceritakan tentang riwayat penyakit/kejadian yang menyebabkan Anak
6
8
Apakah Anak (Almarhum/ah) menderita penyakit
jantung?
.......................................................................................................................................................................................................
1
2
309
401
8
1
epilepsi/ayan?
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
8
Apakah Anak (Almarhum/ah) menderita
1
manis/diabetes? TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
2
NO. PERTANYAAN KATEGORI KODE LANJUT KE
603
A
604
605
605
2
YA _______________________________________________Apakah Anak (Almarhum/ah) menderita 505
506
507
508
509
510
2
8
1
2
8
malnutrisi/kurang gizi? TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
Apakah Anak (Almarhum/ah) menderita kanker?
YA _______________________________________________
JENIS .....................................................................Sebutkan jenis dan lokasi kanker?
Apakah Anak (Almarhum/ah) menderita
508
508
TIDAK TAHU _______________________________________
1
2
8
1
2
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
LOKASI .....................................................................
601
601
2
A
8 A
6. RIWAYAT CEDERA
1
05
06
03
04
01
02
..........................................................................................................................................
Sebutkan jenis diagnosis penyakit lainnya yang
Apakah Anak (Almarhum/ah) mengalami
Jenis cedera apa yang menyebabkan Anak
TIDAK ___________________________________________
KEBAKARAN ____________________________________________________________
KEKERASAN ____________________________________________________________
YA _______________________________________________
511
601
602
JATUH ____________________________________________________________
TENGGELAM ____________________________________________________________
KERACUNAN ____________________________________________________________
TIDAK TAHU _______________________________________
8
bunuh diri?
serangga sehingga meninggal?
1
2
96
(sebutkan)
98
Apakah menurut anda Anak (Almarhum/ah) 1
8
JIKA 10 TAHUN ATAU LEBIH
Apakah cedera tersebut dilakukan oleh
PERIKSA JAWABAN DARI PERTANYAAN 304 UNTUK USIA KEMATIAN ANAK :
B
8 B
2
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
LAINNYA .....................................................................
YA _______________________________________________
TIDAK ___________________________________________
YA _______________________________________________
JIKA KURANG 10 TAHUN
Apakah Anak (Almarhum/ah) digigit binatang/ 1
Apakah Anak (Almarhum/ah) menderita HIV/AIDS?
Apakah Anak (Almarhum/ah) menderita atau
1
TIDAK TAHU ____________________________________________________________
didiagnosis penyakit lain?
diderita Anak (Almarhum/ah)?
cedera yang menyebabkan kematiannya?
NAMA PENYAKIT .....................................................................
(Almarhum/ah) meninggal?
orang lain dengan sengaja?
KECELAKAAN LALU LINTAS ______________________________
2
8
1YA _______________________________________________
TIDAK ___________________________________________
tuberkulosis?
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK TAHU _______________________________________
604
NO. PERTANYAAN KATEGORI KODE LANJUT KE
801
704
704
801
801
808
808
606
B
701
702
703
704
705
706
801
802
803
8. KEADAAN IBU DAN GEJALA YANG DITEMUKAN PADA PERIODE TERAKHIR SAKITNYA ANAK (ALMARHUM/AH)
Berapa lama (hari) sebelum meninggal Bayi
6
8
1
2
Apakah pada saat lahir ukuran Bayi (Almarhum/ah) 1
2
Sebutkan jenis binatang/serangga tersebut!
7. GEJALA DAN TANDA YANG DITEMUKAN PADA PERIODE TERAKHIR SAKITNYA BAYI (ALMARHUM/AH)
JIKA KURANG 1 TAHUN
804
8
2
8
Pada usia kehamilan berapakah (bulan/minggu)
1
9 8
Apakah Anak (Almarhum/ah) mengalami demam?
BULAN ________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
9 8
8
lebih kecil dari normal?
YA _______________________________________________
TIDAK ___________________________________________
ANJING _____________________________________________
ULAR ______________________________________________
SERANGGA _________________________________________
LAINNYA .................................................................
TIDAK TAHU _________________________________________
(sebutkan)
PERIKSA JAWABAN DARI PERTANYAAN 304 UNTUK USIA KEMATIAN ANAK : JIKA 1 TAHUN LEBIH
3
1
2
9 8
Apakah Bayi (Almarhum/ah) tumbuh dengan normal? 1
Apakah Bayi (Almarhum/ah) lahir kurang bulan?
9
Bayi (Almarhum/ah) lahir?
MENGGAMBARKAN UMUR KEHAMILAN
1
MINGGU ____________________________________2
TIDAK TAHU _________________________________
8
3
8
Berapa lama (hari/bulan) Anak (Almarhum/ah)
1
2
Apakah ubun-ubun Bayi (Almarhum/ah) menonjol?
TIDAK TAHU _______________________________________
YA _______________________________________________
Bagaimana keadaan kesehatan ibu sekarang?
menderita sakit sebelum meninggal?
HARI
TIDAK TAHU
SEHAT ______________________________________________
SAKIT __________________________________________________
MENINGGAL _______________________________________________
TIDAK TAHU _________________________________________________
(Almarhum/ah) mengalami ubun-ubun menonjol
tersebut?
1
2TIDAK ___________________________________________
Berapa lama (hari/bulan) Anak (Almarhum/ah)
9 9 8
2
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
mengalami demam?BULAN ________________________________________2
TIDAK TAHU _________________________________
HARI ________________________________________1
BULAN ________________________________________2
TIDAK TAHU _________________________________
HARI ________________________________________1
TIDAK TAHU _______________________________________
9
YA _______________________________________________
701
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
NO. PERTANYAAN KATEGORI KODE LANJUT KE
812
812
818
818
820
820
818
818
sulit bernafas?
819
813
814
815
816
817
818
805
806
807
808
809
810
811
812
YA _______________________________________________Apakah demamnya tinggi?
8
Apakah Anak (Almarhum/ah) mengalami
1
2
2
8
Apakah demamnya terus menerus atau hilang
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
timbul?
mengigil?
TERUS-MENERUS ____________________________________________
HILANG TIMBUL _______________________________________
TIDAK TAHU __________________________________________
8
Apakah Anak (Almarhum/ah) mengalami batuk? 1
2
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
9 8
HARI ___________________________________________
TIDAK TAHU _________________________________
8
1
2
2
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
1
batuk?
Apakah batuknya parah?
Berapa lama (hari) Anak (Almarhum/ah) mengalami
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
nafas cepat?
nafas cepat?
HARI ___________________________________________
TIDAK TAHU _________________________________
1
2
8
2
8
Apakah Anak (Almarhum/ah) muntah setelah batuk?
Apakah Anak (Almarhum/ah) pernah mengalami
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
9 8
1
8
Berapa lama (hari) Anak (Almarhum/ah) mengalami
Apakah Anak (Almarhum/ah) pernah mengalami
9 8
1
2
8
1
2
Apakah nafas Anak (Almarhum/ah) berbunyi YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
Berapa lama (hari) Anak (Almarhum/ah) mengalami
Apakah otot dinding dada bagian bawah Anak
HARI ___________________________________________
9 8
1
otot-otot dinding dada bagian bawah tertarik
ke dalam ketika bernafas?
HARI ___________________________________________
TIDAK TAHU _________________________________
YA _______________________________________________
sulit bernafas?
Berapa lama (hari) Anak (Almarhum/ah) mengalami
(Almarhum/ah) tertarik ke dalam ketika bernafas? TIDAK ___________________________________________
TIDAK TAHU _______________________________________
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
(Almarhum/ah) terlihat kembang kempis? 2
YA _______________________________________________
mengorok/mendengkur/mengi?
* TIRUKAN SUARANYA
Apakah saat bernafas cuping hidung Anak
8
2
1
1
TIDAK TAHU _________________________________
NO. PERTANYAAN KATEGORI KODE LANJUT KE
820
821
822
823
824
825
826
827
828
829
830
831
832
833
834
nyeri perut?
Apakah Anak (Almarhum/ah) pernah mengalami YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
diare?
824
824
9 8
9 8
Ketika diare paling parah, berapa kali buang air
Berapa lama (hari) Anak (Almarhum/ah) mengalami
diare?
besar dalam sehari?
JUMLAH ___________________________________________
TIDAK TAHU _________________________________
TIDAK TAHU _________________________________
8
Berapa lama (hari) Anak (Almarhum/ah)
mengalami muntah?
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
1
2
8
1
2
Apakah Anak (Almarhum/ah) pernah mengalami
muntah?
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
Apakah ada darah dalam tinja?
827
827
HARI ___________________________________________
dalam sehari?9 8
Apakah Anak (Almarhum/ah) mengalami YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
JUMLAH ___________________________________________
TIDAK TAHU _________________________________
9 8
Ketika muntah paling berat, berapa kali muntah
830
830
TIDAK TAHU _________________________________
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
834
834
9 8
Apakah nyeri perutnya hebat? 1
Berapa lama (hari/bulan) Anak (Almarhum/ah)
9
YA _______________________________________________
mengalami nyeri perut?
HARI ________________________________________1
BULAN ________________________________________2
TIDAK TAHU _________________________________
BULAN ________________________________________2
TIDAK TAHU _________________________________
HARI ________________________________________
8
Berapa lama perut Anak (Almarhum/ah) terlihat/
kembung/bengkak dan kencang?
teraba kembung atau kencang?
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
Apakah perut Anak (Almarhum/ah) terlihat/teraba 1
2
lebih? 8
2tidak BAB (Buang Air Besar) selama satu hari atau TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
836
836
8
9 8
1Apakah proses terjadinya penggembungan perut
tersebut terjadi dalam hitungan hari atau hitungan
bulan?
9
CEPAT DALAM HITUNGAN HARI _________________________
BERTAHAP DALAM HITUNGAN BULAN ___________________
TIDAK TAHU _________________________________________
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
Apakah ada benjolan di perut Anak (Almarhum/ah)? 1
2
1
HARI ___________________________________________
2
8
1
2
8
1
2
Apakah Anak (Almarhum/ah) pernah mengalami 1YA _______________________________________________
2
NO. PERTANYAAN KATEGORI KODE LANJUT KE
kaku kuduk?
838
839
840
841
842
843
844
845
846
847
835
836
837
839
839
Berapa lama (hari/bulan) ada benjolan di perut
Anak (Almarhum/ah)?
HARI ________________________________________1
BULAN ________________________________________2
Berapa lama (hari/bulan) Anak (Almarhum/ah)
9
YA _______________________________________________
mengeluh sakit kepala?
Apakah sakit kepalanya berat?
HARI ________________________________________1
BULAN ________________________________________2
TIDAK TAHU _________________________________
8
9 8
1Apakah Anak (Almarhum/ah) mengalami sakit
9
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
kepala?
TIDAK TAHU _________________________________
2
8
Apakah Anak (Almarhum/ah) mengalami kaku
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
8
841
841
844
844
kesadaran atau tidak memberikan reaksi?
9 8
1
Apakah Anak (Almarhum/ah) mengalami penurunan 1
HARI ___________________________________________
TIDAK TAHU _________________________________
8
8
Berapa lama (hari) Anak (Almarhum/ah) mengalami
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
kuduk?2
mengalami kejang?
HARI ________________________________________1
BULAN ________________________________________2
846
846
HARI ___________________________________________
TIDAK TAHU _________________________________
TIBA-TIBA __________________________________________
CEPAT DALAM SEHARI ______________________________________
PERLAHAN DALAM BEBERAPA HARI _________________________
TIDAK TAHU ______________________________________________
Berapa lama (hari) Anak (Almarhum/ah) mengalami
Apakah proses penurunan kesadaran terjadi secara
2
9 8
1Apakah Anak (Almarhum/ah) menderita
9
2
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
kelumpuhan pada tungkai/kaki?
TIDAK TAHU _________________________________
HARI ________________________________________1
849
849
Berapa lama (hari/bulan) Anak (Almarhum/ah)
9 8TIDAK TAHU _________________________________
Berapa lama (hari/bulan) Anak (Almarhum/ah)
9
mengalami kelumpuhan pada tungkai/kaki?BULAN ________________________________________2
3
1
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
9 8
1
2
tiba-tiba, cepat dalam sehari atau perlahan dalam
Apakah Anak (Almarhum/ah) mengalami kejang? YA _______________________________________________
beberapa hari?
penurunan kesadaran atau tidak memberikan reaksi?9 8
2
1
8
2
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
NO. PERTANYAAN KATEGORI KODE LANJUT KE
861
861
856
857
858
859
860
855
854
9
2
Apakah ada perdarahan keluar dari hidung,
Apakah Anak (Almarhum/ah) mengalami
HARI ________________________________________1
BULAN ________________________________________2
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK TAHU _______________________________________
848
849
850
851
852
853
Apakah ada perubahan jumlah air seni yang
tiba-tiba, dalam sehari atau perlahan dalam
beberapa hari?
YA _______________________________________________
1
8
CEPAT DALAM SEHARI ______________________________________
TIBA-TIBA __________________________________________Apakah kelumpuhan pada kaki terjadi secara
2 852
852
9 8
Berapa lama (hari/bulan) perubahan jumlah air seni
tersebut dialami Anak (Almarhum/ah)?
Berapa banyak jumlah air seni yang dikeluarkan
Anak (Almarhum/ah) dalam sehari?
dikeluarkan Anak (Almarhum/ah) dalam sehari?
8
Dimana lokasi bintik-bintik merah tersebut? Y T TT
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
PERLAHAN DALAM BEBERAPA HARI _________________________
TIDAK TAHU ______________________________________________
HARI ________________________________________1
BULAN ________________________________________2
TIDAK TAHU _________________________________
1
8
1
Berapa lama (hari) Anak (Almarhum/ah) mengalami
Selama sakit yang menyebabkan kematiannya,
apakah Anak (alamarhum/ah) menderita
bintik-bintik merah (ruam) di kulit?
TIDAK TAHU _________________________________
TERLALU BANYAK _________________________________________
TERLALU SEDIKIT __________________________________________
TIDAK TAHU _______________________________________
TIDAK ADA AIR SENI SAMA SEKALI ______________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
HARI ___________________________________________
2
3
856
856
2
8
1
2
3
8
Apakah Anak (Almarhum/ah) mengalami
1
2
1 2 83.
Seperti apa bentuk bintik-bintik merah (ruam)
tersebut?
LENGAN DAN KAKI3.
RUAM CAMPAK ____________________________________________
RUAM BERISI CAIRAN BENING ___________________________
RUAM BERISI PUS (NANAH) _______________________________
TIDAK TAHU _________________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
Lengan dan kaki?
mata merah?
8
1
9 8
1Apakah Anak (Almarhum/ah) terlihat sangat kurus?
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
TIDAK TAHU _________________________________
YA _______________________________________________
8
Berapa lama (hari/bulan) Anak (Almarhum/ah)
9
TIDAK ___________________________________________
mulut atau anus?
penurunan berat badan?
mengalami penurunan berat badan?
2
8
Badan? 8
1 21.
bintik-bintik merah (ruam) di kulit?
MUKAMuka?
2
3
8
BADAN 1 2
1
1
2
2.
1.
2.
9 8
8
NO. PERTANYAAN KATEGORI KODE LANJUT KE
863
863
866
866
869
869
871
871
873
873
861
862
863
864
865
866
869
870
871
872
868
9
9
9
8
1
Muka?
Sendi?
MUKA
SENDI
1.
2.
1.
2. 1 2 8
1
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
1
2
Berapa lama (hari) Anak (Almarhum/ah) mengalami
Apakah ada luka/bercak putih di lidah atau
867
HARI ___________________________________________
TIDAK TAHU _________________________________
9TIDAK TAHU _________________________________
Berapa lama (hari/bulan) Anak (Almarhum/ah)
mengalami pembengkakan tersebut?
luka/bercak putih pada lidah atau mulut?
mulut Anak (Almarhum/ah)?
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
Anak (Almarhum/ah)?
9 8
1Apakah terdapat pembengkakan pada bagian tubuh
2
3. 1 2 8Pergelangan Kaki?
Seluruh Tubuh?
Tempat Lain?
PERGELANGAN KAKI
SELURUH TUBUH
TEMPAT LAIN
3.
4.
5.
4.
Dimana lokasi pembengkakan tersebut? Y T TT
Apakah ada benjolan kelenjar getah bening
(kelenjar leher, ketiak, sela paha) di tubuh
Anak (alamarhum/ah) ?
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
1. 1 2 8
9 8
Y T TT
5. 1 2 8
seperti rambut jagung?
2
8
Berapa lama (hari/bulan) bagian putih mata Anak
TIDAK ___________________________________________
Apakah bagian putih mata Anak (Almarhum/ah) 1
4. 1 2Tempat Lain?
berubah menjadi kuning?
1
8
9 8atau kekuningan ?
(Almarhum/ah) menjadi kuning?
YA _______________________________________________
Berapa lama (hari/bulan) Anak (Almarhum/ah)
mengalami rambut kemerah-merahan
8
9 8
Apakah rambut Anak (Almarhum/ah) berubah
kemerah-merahan atau kekuningan
YA _______________________________________________
3. 1 2 8
Dimana lokasi benjolan kelenjar getah bening tersebut?
mengalami benjolan kelenjar getah bening tersebut?
Berapa lama (hari/bulan) Anak (Almarhum/ah)
Leher?
HARI ________________________________________
2 8
HARI ________________________________________1
BULAN ________________________________________
2. 1 2 8Ketiak?
Selangkangan?
2
TIDAK TAHU _______________________________________
2
(sebutkan) ..........................................................................
9 8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
2
8
1
1 2 8
YA _______________________________________________
BULAN ________________________________________2
TIDAK TAHU _________________________________
HARI ________________________________________1
BULAN ________________________________________2
TIDAK TAHU _________________________________
HARI ________________________________________1
BULAN ________________________________________2
TIDAK TAHU _________________________________
1. LEHER
2. KETIAK
3. SELANGKANGAN
4. TEMPAT LAIN
(sebutkan) ..........................................................................
NO. PERTANYAAN KATEGORI KODE LANJUT KE
875
875
901
901
909
873
874
875
876
901
902
903
904
905
906
907
(lemah/kurang darah ) atau terlihat pucat pada
telapak tangan,mata atau bantalan kuku?
Berapa lama (hari) Anak (Almarhum/ah)
terlihat pucat?
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
HARI ___________________________________________
1
campak?
2
Apakah Anak (Almarhum/ah) kelihatan pucat YA _______________________________________________
9. PENGOBATAN DAN PELAYANAN KESEHATAN PADA EPISODE SAKIT TERAKHIR
YA _______________________________________________
TIDAK TAHU _________________________________
Berapa lama (hari) Anak (Almarhum/ah) mengalami
9 8
Sebutkan jenis obat (pengobatan) apa saja yang ...............................................................................................
909
8
9 8
1YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
TIDAK TAHU _________________________________
HARI ___________________________________________
Apakah mata Anak (Almarhum/ah) cekung?
mata cekung?
2
Apakah Anak (Almarhum/ah) pernah diimunisasi 1
SALIN RESEP/CATATAN KUITANSI JIKA ADA
untuk penyakit terakhirnya sebelum meninggal?
diberikan kepada Anak (Almarhum/ah) untuk
penyakit yang menyebabkannya meninggal?
1
2
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________8
4.
2.
1 2 83.
1
1 2 8
pemberian cairan melalui infus?
Transfusi darah?
Pemberian makanan/obat dengan selang
yang dipasang melalui hidung (NGT)?
2
Apakah Anak (Almarhum/ah) mendapat pengobatan
Pengobatan Tradisional?
Puskesmas?
PENGOBATAN TRADISIONAL
PUSKESMAS
1.
pengobatan untuk sakit yang menyebabkannya
meninggal?1
8
Rehidrasi oral (minum oralit) dan atau
Dimana saja Anak (Almarhum/ah) mendapatkan
3.
2.
Jenis pengobatan apa saja yang diterima?Y T TT
1.
1 2
8
1 2
2
PENGOBATAN LAINNYA
1.
2.
Y T TT
1 2 87.
1
Jenis pengobatan lainnya? (sebutkan) ..........................................................................
1 2 85.
1 2 8
RS Pemerintah?
Klinik Swasta?
RS Swasta?
RS PEMERINTAH
KLINIK SWASTA
RS SWASTA
4.
5.
6.
2 83.
1 2 84.
2.1
8
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
9 8
2 88.
Sebelum meninggal, berapa kali Anak
8
909
909
penyakit/penyebab kematiannya?
JUMLAH PERIKSA _______________________________
TIDAK TAHU _________________________________
Apakah petugas kesehatan menjelaskan
TEMPAT LAINNYA8.
(sebutkan) ..........................................................................
Rumah?RUMAH1.
(Almarhum/ah) pernah mendapatkan pelayanan
oleh petugas kesehatan?
Tempat Lain?
Apotik, Toko Obat, Warung?
6.
1YA _______________________________________________
2
...............................................................................................
...............................................................................................
...............................................................................................
...............................................................................................
2 8
8
3.
4.
APOTIK, TOKO OBAT, WARUNG7.
ORALIT/INFUS CAIRAN
TRANSFUSI DARAH
NGT
NO. PERTANYAAN KATEGORI KODE LANJUT KE
1003
1101
1101
1106
1003
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
1101
1102
1103
1001
10. DATA YANG TERTULIS DARI SURAT KETERANGAN KEMATIAN
2
8
908
909
910
911
1002
1003
1004
2
8
8
Surat Keterangan Kematian?
...............................................................................................
YA _______________________________________________
11. KETERANGAN PENDUKUNG DARI CATATAN KESEHATAN LAINNYA
Apakah ada keterangan kesehatan pendukung 1
2
SALINLAH SEMUA KETERANGAN MEDIS YANG MENDUKUNG DARI DUA PELAYANAN KESEHATAN TERAKHIR (JIKA LEBIH DARI
DUA) DAN CATAT TANGGAL KETERANGAN MEDIS TERSEBUT (CATAT INFORMASI MENGENAI IBU DAN ANAK)
SURAT IZIN PENGUBURAN (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM SURAT TERSEBUT)
..........................................................................................................................................................................................................................................
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
Apakah Anak (Almarhum/ah) mempunyai 1
lainnya?
DIKELUARKANNYA AKTE KEMATIAN?
TANGGAL BULAN TAHUN
Apa yang dijelaskan oleh petugas kesehatan tentang
YA _______________________________________________
penyebab kematiannya?
Apakah Anak (Almarhum/ah) menjalani operasi
Bagian tubuh mana yang dioperasi?
TIDAK TAHU _________________________________
1
...............................................................................................
...............................................................................................
...............................................................................................
1
1001
1001
(Bolehkan saya melihat akte kematian tersebut?)TANGGAL BULAN TAHUN
YA _______________________________________________
TIDAK ___________________________________________
TIDAK TAHU _______________________________________
PERUT ___________________________________________
DADA ___________________________________________________
KEPALA ______________________________________________
TIDAK TAHU ____________________________________________
2
LAINNYA ...............................................................................................
(sebutkan)
Berapa lama (hari) sebelum meninggal operasi
TIDAK ___________________________________________
Kematian yang dikeluarkan oleh Kantor Dinas
Kependudukan dan Catatan Sipil?
6
8
SALIN TANGGAL, BULAN, DAN TAHUN KEMATIAN
DARI SURAT KETERANGAN KEMATIAN
Apakah Anak (Almarhum/ah) memiliki Akte 1
..........................................................................................................................................................................................................................................
untuk pengobatan penyakitnya?
HARI ___________________________________________
TIDAK TAHU _______________________________________
2
3
9 8
TIDAK ___________________________________________
(Bolehkan saya melihat akte kematian tersebut?)
SALIN TANGGAL, BULAN, DAN TAHUN
..........................................................................................................................................................................................................................................
tersebut dilakukan?
YA _______________________________________________
NO. PERTANYAAN KATEGORI KODE LANJUT KE
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
CATATAN PEWAWANCARA
DIISI SETELAH WAWANCARA SELESAI
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
1104
1105
1106
..........................................................................................................................................................................................................................................
CATATAN WAKTU AKHIR WAWANCARA
HASIL PEMERIKSAAN VISUM/AUTOPSY FORENSIK (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM
HASIL VISUM TERSEBUT)
..........................................................................................................................................................................................................................................
BUKU KIA/KMS (SALINLAH INFORMASI YANG BERHUBUNGAN DENGAN KESEHATAN IBU DAN ANAK (ALMARHUM/AH))
JAM
MENIT
..........................................................................................................................................................................................................................................
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12. RESUME DAN DIAGNOSA (Dibuat oleh Dokter)
RESUME AUTOPSI VERBAL : ..........................................................................................................................................................................................................................................
NAMA DOKTER : ..........................................................................................................................................................................................................................................
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NAMA DOKTER :.....................................................................................................TANDA TANGAN DOKTER : .....................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
TANGGAL DIAGNOSIS :.....................................................................................................
disebabkan oleh
d.
....................................................................................................................................................................
II. PENYAKIT/KONDISI LAIN YANG BERKONTRIBUSI
NAMUN TIDAK BERHUBUNGAN DENGAN I a-d
disebabkan oleh
c.
....................................................................................................................................................................
disebabkan oleh
b.
....................................................................................................................................................................
a.
....................................................................................................................................................................
SELANG WAKTU MULAI TERJADINYA PENYAKIT SAMPAI MENINGGALI. PENYEBAB KEMATIAN MENURUT DOKTER PUSKESMAS
THN BLN HARI JAM ICD -10
Propinsi Kab/Kota Kecamatan Kel/Desa No. Urut Kasus
ID/NOMOR REFERENSI KONTROL
( )
RESPONDEN SETUJU DIWAWANCARAI : 1. SETUJU DIWAWANCARAI
2. MENOLAK DIWAWANCARA → AKHIRI
Nama Responden : ( ) Nama Saksi :
NO. TELEPON / HP ..............................................................................................................................................................................
INFORMED CONSENT
Selamat pagi/siang/sore/malam, Nama saya................................... dan saya bekerja di........................................ Kami sedang mengumpulkan data tentang penyebab
kematian di daerah ini. Kami sangat senang sekali apabila Bapak/Ibu dapat ikut berpartisipasi dalam kegiatan ini. Kami akan bertanya mengenai keadaan yang
menyebabkan kematian. Informasi apapun yang Bapak/Ibu berikan akan kami simpan dan dirahasiakan. Identitas Bapak/Ibu (responden) maupun
almarhum/ah.............................. tidak akan kami beri tahu kepada siapapun. Partisipasi untuk kegiatan ini adalah sukarela dan Bapak/Ibu dapat memilih untuk
bersedia menjawab sebagian pertanyaan atau tidak bersedia menjawab semuanya. Bapak/Ibu dapat menghentikan wawancara kapan saja tanpa ada konsekuensi.
Kami berharap Bapak/Ibu dapat ikut berpartisipasi dalam kegiatan ini, karena hal ini akan membantu pemerintah untuk meningkatkan pelayanan kesehatan
khususnya di daerah ini. Sekarang ini apakah Bapak/Ibu ingin bertanya mengenai tujuan dan isi dari wawancara ini? Bolehkah saya memulai wawancara ini
sekarang?
Tanda Tangan Responden : ................................................... Tanda Tangan Saksi : ...................................................
10. ALAMAT LENGKAP ALMARHUM/AH ............................................................................................................................................................................................................................................................
RT/RW/KELURAHAN/DESA .............................................................................................................................................................................................
............................................................................................................................................................................................................................................................
7. NAMA KEPALA RUMAH TANGGA.....................................................................................................................................................................................................................................................
8. NAMA RESPONDEN.....................................................................................................................................................................................................................................................
9. STATUS KEPENDUDUKAN ALMARHUM/AH 1. Penduduk 2. Bukan Penduduk
5. NOMOR KASUS KEMATIAN.....................................................................................................................................................................................................................................................
6. NAMA ALMARHUM/AH.....................................................................................................................................................................................................................................................
3. KECAMATAN.....................................................................................................................................................................................................................................................
4. KELURAHAN/DESA.....................................................................................................................................................................................................................................................
1.3 DATA DEMOGRAFI
1. PROVINSI......................................................................................................................................................................................................................................................
2. KABUPATEN.....................................................................................................................................................................................................................................................
2. TANGGAL ...................................
1. NAMA ...................................
1.2 KETERANGAN PENGAWAS/EDITOR
PENGAWAS/EDITOR EDITOR PUSAT KODE PENGENTRI
1 2 3
HASIL KUNJUNGAN :
1. Lengkap 2. RT Tidak ada dirumah 3. Ditunda 4. Ditolak
5. Tidak lengkap 6. Responden tidak dapat dijumpai 7. Lainnya (sebutkan) ...................................................................
5. JUMLAH KUNJUNGAN4. TANGGAL ................................... ...................................
5. WAKTU ................................... ...................................
0 1
4. HASIL KUNJUNGANRENCANA KUNJUNGAN BERIKUTNYA :
3. HASIL KUNJUNGAN* 3. TAHUN 2
2. NAMA PEWAWANCARA ................................... ................................... ................................... 2. BULAN
1. TANGGAL ................................... ................................... ................................... 1. TANGGAL
1. KUNJUNGAN WAWANCARA
1.1 KETERANGAN KUNJUNGAN 1 2 3 4. KUNJUNGAN AKHIR
Propinsi Kab/Kota Kecamatan Kel/Desa No. Urut Kasus
KUESIONER AUTOPSI VERBAL 3UNTUK KEMATIAN UMUR DIATAS 15 TAHUN
ID/NOMOR REFERENSI KONTROL
1
`
IBU _______________________________________________
SAUDARA _______________________________________
HUBUNGAN LAINNYA ..........................................................................
Berapa umur Almarhum/ah saat meninggal?
Apakah pekerjaan utama Almarhum/ah?
BULAN
TAHUN
Kapan Almarhum/ah lahir?
(sebutkan)
TIDAK ADA HUBUNGAN ___________________________
almahum/ah?
PEREMPUAN _______________________________
8
6
Apakah Bapak/Ibu/Sdr/i tinggal dengan almahum/ah 1
2pada saat menjelang kematiannya?
YA _________________________________________________
SUAMI/ISTRI _______________________________________3
302 Apa jenis kelaminnya? 1
2
UMUR DALAM TAHUN
TIDAK BEKERJA ________________________________
08
LAINNYA ..........................................................................
LAKI-LAKI _________________________________________
TANGGAL
304
303
→ JIKA TAHUN TIDAK DIKETAHUIKODE 9998
3. KETERANGAN ALMARHUM/AH DAN TANGGAL/TEMPAT KEMATIAN
301 Siapakah nama Almarhum/ah? ................................................................................................
KODE 98 → JIKA TANGGAL DAN BULAN TIDAK DIKETAHUI
305
................................................................................................
JAM
MENIT
UMUR DALAM TAHUN
TAMAT PT __________________________________________
202 Nama Responden
KATEGORI KODE LANJUT KE
2. KETERANGAN RESPONDEN
TAMAT SLTP ______________________________________
TAMAT SLTA __________________________________________
Umur Responden
Jenis Kelamin Responden LAKI-LAKI _________________________________________
PEREMPUAN ___________________________________
TIDAK SEKOLAH _____________________________________
TIDAK TAMAT SD _____________________________________
TAMAT SD ___________________________________________
1
NO. PERTANYAAN
201 Catatan waktu awal wawancara
2
1
2
203
204
(sebutkan)
96
01
02
03
04
05
06
07
206 Apakah hubungan Bapak/Ibu/Sdr/i dengan
3
4
5
6
AYAH ______________________________________________
2
4
TIDAK _______________________________________________
ANAK _______________________________________5
207
205 Apakah pendidikan terakhir Bapak/Ibu/Sdr/i?
SEKOLAH _______________________________________
TNI/POLRI ___________________________________________
PNS ______________________________________________
WIRASWASTA/DAGANG _____________________________
PETANI ____________________________________________
NELAYAN _________________________________________
BURUH _________________________________________
KATEGORI KODE LANJUT KENO. PERTANYAAN
Apakah pendidikan tertinggi Almarhum/ah?
→ JIKA TANGGAL DAN BULAN TIDAK DIKETAHUI
KODE 9998 → JIKA TAHUN TIDAK DIKETAHUI
Apakah Almarhum/ah menderita darah tinggi?
TIDAK TAMAT SD ____________________________________
BELUM MENIKAH ____________________________________
MENIKAH ________________________________________
Mohon katakan jika Almarhum/ah mengalami penyakit seperti berikut :
FASILITAS KESEHATAN LAINNYA _______________________
RUMAH ___________________________________________
TAHUN
LAINNYA ..........................................................................
TIDAK TAHU ______________________________________
TAMAT SD _______________________________________
TAMAT SMP _______________________________________
TAMAT SMA ______________________________________
.......................................................................................................................................................................................................
.......................................................................................................................................................................................................
3
HIDUP BERPISAH _________________________________
TIDAK TAHU ______________________________________
TAMAT DIPLOMA ___________________________________
TAMAT PT _________________________________________
TIDAK TAHU _________________________________________
KODE 98
CERAI HIDUP _____________________________________
BULAN
2
RUMAH SAKIT ___________________________________
308 Kapan Almarhum/ah meninggal?
4
1
TANGGAL
306
CERAI MATI _____________________________________
TIDAK SEKOLAH _______________________________________
YA ______________________________________________
5
2
Almarhum/ah meninggal? ..................................................................................................................................
.......................................................................................................................................................................................................
402 Penyebab kematian berdasarkan responden : ...............................................................................................................
.......................................................................................................................................................................................................
307 Status perkawinan Almarhum/ah? 1
8
309 Di manakah Almarhum/ah meninggal? 1
Saya ingin menanyakan tentang keadaan penyakit yang pernah diderita Almarhum/ah sebelum saat meninggalnya,
kejadian cedera atau kecelakaan yang pernah dialami, dan tanda dan gejala yang dialami oleh Almarhum/ah saat
sakitnya. Beberapa pertanyaan mungkin tidak berhubungan langsung dengan penyebab kematian Almarhum/ah. Kami
mengharap kesabaran anda untuk menjawab pertanyaan. Jawaban anda akan membantu kami untuk mendapatkan
kejelasan tanda dan gejala yang pernah dialami oleh Almarhum/ah saat sakitnya.
8
502 1
2TIDAK ___________________________________________
TIDAK TAHU ______________________________________8
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
501 1
5. RIWAYAT PENYAKIT/MEDIS ALMARHUM/AH SEBELUMNYA
6
8
4. PENJELASAN RESPONDEN TENTANG PENYAKIT/KEJADIAN YANG MENYEBABKAN KEMATIAN
401 Dapatkah Bapak/Ibu/Sdr menceritakan tentang riwayat penyakit/kejadian yang menyebabkan
.......................................................................................................................................................................................................
diabetes?
Apakah Almarhum/ah menderita kencing manis/
(sebutkan)
2
3
8
3
4
5
6
7
2
KATEGORI KODE LANJUT KENO. PERTANYAAN
Apakah Almarhum/ah menderita kanker?
Apakah Almarhum/ah menderita epilepsi/ayan?
2
2
504 1
2
8
503 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
Apakah Almarhum/ah menderita asma?
505 1
2
8
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
507
2
8
506 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
Sebutkan jenis dan lokasi kanker? JENIS ............................................................................
Apakah Almarhum/ah menderita malnutrisi/
kurang gizi?
2
8
508 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
Apakah Almarhum/ah menderita tuberkulosis?
Apakah Almarhum/ah menderita HIV/AIDS?
LOKASI ............................................................................
8
508
508
510 1
2
8
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
Apakah Almarhum/ah pernah menderita
atau didiagnosis penyakit lain?
509 1
601
6. RIWAYAT CEDERA
601 1
511
............................................................................
NAMA PENYAKIT ............................................................................
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
Sebutkan jenis diagnosis penyakit lainnya yang
diderita Almarhum/ah?
Apakah Almarhum/ah mengalami cedera yang
menyebabkan kematian?
8 601
604
604
602 01
02
Apakah jenis cedera yang menyebabkan
(sebutkan)
2
Almarhum/ah meninggal?
KECELAKAAN LALU LINTAS __________________________
JATUH ___________________________________________
603 1
2
96
98
05
06
03
04
YA ______________________________________________
TIDAK ___________________________________________
Apakah cedera tersebut dilakukan oleh
orang lain dengan sengaja?
(sebutkan)
TENGGELAM _____________________________________
KERACUNAN ............................................................................
KEBAKARAN _____________________________________
KEKERASAN ________________________________________
LAINNYA ............................................................................
TIDAK TAHU ____________________________________
8
604 Apakah menurut anda Almarhum/ah
8TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
bunuh diri?
1
2
8
KATEGORI KODE LANJUT KENO. PERTANYAAN
701
8
1
2
1
Berapa lama (hari/bulan) Almarhumah mengalami
YA ______________________________________________
1
2
melalui vagina di luar masa menstruasi/haid?
BULAN ________________________________
MINGGU ____________________________
TIDAK TAHU ______________________________
1
2
9
MINGGU ____________________________
8
ulkus/luka atau pembengkakan?
BULAN ________________________________
keputihan atau keluar cairan tidak normal dari vagina?
YA ______________________________________________
8
Sebutkan jenis binatang/serangga tersebut! ANJING __________________________________________
ULAR ____________________________________________
SERANGGA ______________________________________
TIDAK TAHU ____________________________________
LAINNYA ............................................................................
(sebutkan)
3
6
605 1
2
Apakah Almarhum/ah digigit binatang/serangga YA ______________________________________________
TIDAK ___________________________________________sehingga meninggal? A
606 1
2
8TIDAK TAHU ______________________________________
7. GEJALA DAN TANDA YANG DITEMUKAN PADA PERIODE TERAKHIR UNTUK PEREMPUAN (ALMARHUMAH)
701 Apakah pada payudara Almarhumah terdapat 1
8
2
ulkus/luka atau pembengkakan pada payudaranya?
702
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
BULAN ________________________________
MINGGU ____________________________
2
705
TIDAK TAHU ______________________________
TIDAK TAHU ______________________________________
Apakah Almarhumah mengalami perdarahan 1
704
banyak perdarahan selama menstruasi/haid?
Berapa lama (hari/bulan) Almarhumah mengalami
TIDAK TAHU ______________________________
BULAN ________________________________
MINGGU ____________________________
TIDAK TAHU ______________________________
perdarahan selama menstruasi/haid?
9
YA ______________________________________________
2
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
9
8
707 Apakah dari vagina Almarhumah keluar cairan 1
yang tidak normal (keputihan)? 2
banyak perdarahan selama menstruasi/haid?
706 Berapa lama (hari/bulan) Almarhumah mengalami
8
2
9 8
9 8
TIDAK ___________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
8. GEJALA DAN TANDA YANG BERHUBUNGAN DENGAN KEHAMILAN
801 Apakah Almarhumah sedang hamil atau melahirkan, 1
A
JIKA "PEREMPUAN"
PERIKSA JAWABAN DARI PERTANYAAN 302 UNTUK JENIS KELAMIN ALMARHUM/AH : JIKA "LAKI-LAKI"
8
89
atau nifas ketika meninggal?2
703 Apakah Almarhumah mengalami banyak 1
901
708 Berapa lama (hari/bulan) Almarhumah mengalami
9
9
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
703
703
705
705
707
707
801
801
818
818
A
KATEGORI KODE LANJUT KENO. PERTANYAAN
______
termasuk kehamilan terakhir?
1 2
9 8
PERDARAHAN DARI VAGINA
2
1 2
2 8
Berapa kali Almarhumah mengalami kehamilan,
Y
Perdarahan dari Vagina?
BULAN ________________________________
MINGGU ____________________________
TIDAK TAHU ______________________________
KEHAMILAN ________________________________
TIDAK TAHU ___________________________
8
1
tersebut dibawah ini :
2
Kejang?
Demam Tinggi?
1 2
T
2 8
apakah Almarhumah mengalami hal-hal
Selama 3 bulan terakhir kehamilannya,804
Sakit Perut Hebat (Bukan sakit persalinan)?
1 2 8
805 Apakah Almarhumah meninggal ketika 1
8
9.
8. 1 2
4. 1
8
YA ______________________________________________
8
5.
7.
6. 1
10.
Pucat dan Nafas Cepat?
Penyakit Lain?
6.
7.
8.
9.
10.
8
806 1
< 42 hari setelah melahirkan? 2
sedang bersalin, tetapi anak belum lahir? 2
8
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
meninggal?
807 Berapa hari setelah melahirkan Almarhumah JAM ________________________________1
HARI ____________________________ 2
TIDAK TAHU ______________________________9
Apakah Almarhumah meninggal saat bersalin atau
818
818
808 Apakah Almarhumah mengalami perdarahan 1
8
YA ______________________________________________
810 Apakah Almarhumah mengalami perdarahan 1
hebat pada saat awal timbulnya tanda-tanda 2
persalinan (kala 1)? 8
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
809 Apakah Almarhumah mengalami perdarahan 1
hebat selama proses persalinan sebelum bayi
9 8
lahir? 8
812 Apakah Almarhumah mengalami proses 1
persalinan yang lama (>24 jam)? 2
8
811 Apakah Almarhumah mengalami kesulitan 1
ketika melahirkan placenta? 2
8
YA ______________________________________________
TIDAK ___________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
hebat setelah bayi lahir? 2
8TIDAK TAHU ______________________________________
3. 1
2.
1.
1802 Jika ya, berapa usia kehamilan terakhir?
1 2
8
TT
803
9 9 8
Keluar Cairan Vagina Bau?
2
8
DEMAM TINGGI
SAKIT PERUT HEBAT
PUCAT DAN NAFAS CEPAT
PENYAKIT LAIN
(sebutkan) ............................................................................
1.
2.
3.
4.
5.
KELUAR CAIRAN VAGINA BAU
WAJAH BENGKAK
SAKIT KEPALA
PANDANGAN KABUR
KEJANG
Wajah Bengkak?
Sakit Kepala?
Pandangan Kabur?
2
KATEGORI KODE LANJUT KENO. PERTANYAAN
dalam waktu dekat sebelum meninggal?
POLINDES _____________________________________
PRAKTEK BIDAN ___________________________________
RUMAH _________________________________________
LAINNYA ..........................................................................
(sebutkan)
98
814 Bagaimana cara proses persalinannya? 1
2
2
8
813 1Apakah Almarhumah melahirkan secara normal?
FORCEP _____________________________________
VAKUM _________________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
815 Apakah Almarhumah mengeluarkan cairan 1
vagina yang berbau? 2
8
3
6
YA ______________________________________________
TIDAK ___________________________________________
OPERASI SEKSIO/SESAR _______________________________
LAINNYA ..........................................................................
TIDAK TAHU ______________________________________
(sebutkan)
816 Dimana Almarhumah melahirkan? 01
02
03
TIDAK TAHU ______________________________________
RUMAH SAKIT ____________________________________
PUSKESMAS ______________________________________
RUMAH BERSALIN __________________________________
817 Siapakah yang menolong persalinan?
96
98
01
02
03
05
06
04
TIDAK TAHU ______________________________________
DOKTER _____________________________________
BIDAN ________________________________________
PERAWAT ____________________________________
8
818 Apakah Almarhumah mengalami keguguran
96
1
04
05
06
YA ______________________________________________
TIDAK ___________________________________________
keguguran? 2
8
8
819 Apakah Almarhumah meninggal saat mengalami 1
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
LAINNYA ..........................................................................
(sebutkan)
TIDAK TAHU ______________________________________
2
DUKUN BERSALIN _______________________________
KELUARGA ______________________________________
IBU SENDIRI _____________________________________
821 Berapa bulan umur kehamilannya saat
9 8
820 Berapa hari sebelum meninggal Almarhumah
perdarahan hebat setelah keguguran? 2
8
9 8
822 Apakah Almarhumah mengalami 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
TIDAK TAHU ____________________________Almarhumah mengalami keguguran?
mengalami keguguran?
HARI ______________________________________
TIDAK TAHU ______________________________
BULAN _______________________________
dengan sendirinya secara spontan? 2
8
823 Apakah keguguran tersebut terjadi 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
(KEGUGURAN : HAMIL < 22 MINGGU) 901
821
821
901
901
901
815
815
KATEGORI KODE LANJUT KENO. PERTANYAAN
TIDAK ___________________________________________
2
1
TIDAK TAHU ______________________________
YA ______________________________________________
TIDAK TAHU ______________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
2
MINGGU ________________________________
BULAN ____________________________
8TIDAK TAHU ______________________________________
YA ______________________________________________
909 Apakah batuknya parah? 1
Apakah demamnya terus menerus atau 1
824 Apakah Almarhumah menggunakan obat atau 1YA ______________________________________________
menderita sakit sebelum meninggal?
9. GEJALA DAN TANDA YANG DITEMUKAN PADA PERIODE TERAKHIR SAKITNYA ALMARHUM/AH
901 Berapa lama (minggu/bulan) Almarhum/ah
melakukan tindakan untuk menginduksi / 2
memicu terjadinya keguguran? 8
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
8
8
902 Apakah Almarhum/ah mengalami 1
demam?2
904
9 89
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
hilang timbul?2
TIDAK TAHU ______________________________
demam?
HARI ________________________________1
BULAN ____________________________ 2
TIDAK TAHU ______________________________9
batuk?
908 Berapa lama (hari/bulan) Almarhum/ah mengalami
menggigil? 2
903 Berapa lama (hari) Almarhum/ah mengalami
9 8
TERUS-MENERUS ___________________________
HILANG TIMBUL ____________________________________
TIDAK TAHU ________________________________________
906 Apakah Almarhum/ah mengalami 1
Apakah Almarhum/ah mengalami demam hanya
pada malam hari?
8
905 1
2
YA ______________________________________________
BULAN ____________________________
1
TIDAK ___________________________________________
910 Apakah batuknya berdahak (produktif)? 1
2
8
2
8
907 Apakah Almarhum/ah mengalami batuk? 1
2
8TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
912 Apakah Almarhum/ah mengalami keringat 1
malam tanpa melakukan aktifitas sebelumnya? 2
8
911 Apakah ketika batuk keluar darah? 1
(batuk berdarah) 2
8
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
9 89
HARI ________________________________
907
907
913
913
KATEGORI KODE LANJUT KENO. PERTANYAAN
1
2
TIDAK TAHU ______________________________
1
2
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
TIDAK ___________________________________________
harus diganjal oleh beberapa bantal?
2
terasa di ulu hati dibawah tulang tengah dada? 2
TERUS MENERUS ___________________________________
HILANG TIMBUL _________________________________
8
919 Berapa lama (hari/bulan) Almarhum/ah mengalami
TIDAK TAHU ______________________________________
HARI ________________________________
BULAN ____________________________
TIBA-TIBA _________________________________________
PERLAHAN-LAHAN _______________________________
TIDAK TAHU ______________________________
8
nyeri dada?
8
920 Apakah nyeri dada timbul secara tiba-tiba atau 1
perlahan-lahan?2
923 1
2terasa dibagian jantung dan menyebar ke lengan
8
924 Apakah nyeri dada yang dialami Almarhum/ah 1
terasa dibagian tulang iga?
melakukan aktivitas rutin sehari-hari disebabkan
8
913 Apakah Almarhum/ah pernah mengalami sulit 1
bernafas? 2
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
915 Apakah Almarhum/ah pernah tidak dapat 1
2
sulit bernafas?
914 Berapa lama (hari/bulan) Almarhum/ah mengalami
9 89
HARI ________________________________
BULAN ____________________________
YA ______________________________________________
TIDAK ___________________________________________
916 Apakah Almarhum/ah sulit bernafas jika dalam 1
keadaan berbaring pada posisi datar sehingga 2
mengalami sulit bernafas? 8
918 Apakah Almarhum/ah pernah mengalami nyeri 1
dada? 2
8
917 Apakah Almarhum/ah ketika bernafas 1
mengeluarkan bunyi mengi? 2
* TIRUKAN SUARANYA
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
9 89
TIDAK TAHU ____________________________________
2
922 Apakah nyeri dada yang dialami Almarhum/ah 1
berlangsung?3
921 Ketika Almarhum/ah mengalami nyeri dada 1
terparah, berapa lama kejadian tersebut2
< SETENGAH JAM ________________________________
SETENGAH JAM - 24 JAM __________________________
LEBIH DARI 24 JAM _____________________________
TIDAK TAHU ___________________________________
YA ______________________________________________
8TIDAK TAHU ____________________________________
terasa terus menerus atau hilang timbul?
8
Apakah nyeri dada yang dialami Almarhum/ah
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________kiri? 8
8
925 Apakah nyeri dada yang dialami Almarhum/ah 1
918
918
928
928
KATEGORI KODE LANJUT KENO. PERTANYAAN
PERIKSA JAWABAN DARI PERTANYAAN 801, 805, 819 UNTUK MELIHAT APAKAH
2
JIKA "TIDAK"
diare?
muntah?
BULAN ____________________________ 2
2
9 89TIDAK TAHU ______________________________
8
8
8
JIKA "PEREMPUAN"
C
Apakah Almarhum/ah pernah mengalami diare? 1
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
927 Apakah Almarhum/ah mengalami jantung 1
berdebar-debar? 2
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
928
929 Berapa lama (hari/bulan) Almarhum/ah mengalami
8TIDAK TAHU ______________________________________
HARI ________________________________1
8
926 Apakah nyeri dada dirasakan semakin 1
parah ketika Almarhum/ah batuk?
930 Apakah diare yang dialami Almarhum/ah 1
terus menerus atau hilang timbul? 2
9 89
TERUS MENERUS ___________________________________
HILANG TIMBUL _________________________________
TIDAK TAHU ____________________________________
TIDAK TAHU ______________________________
8
2
932 Ketika diare paling parah, berapa kali buang air JUMLAH
dalam tinja almarhum/ah? 8
931 Selama menderita penyakit terakhir (sebelum 1
meninggal), apakah pernah terdapat darah di 2
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
933 Apakah Almarhum/ah pernah mengalami 1
besar dalam sehari? TIDAK TAHU
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
muntah?
934 Berapa lama (hari/bulan) Almarhum/ah mengalami HARI ________________________________1
BULAN ____________________________ 2
B
B8
9
936 Ketika muntah paling parah, berapa kali muntah
(seperti darah) atau lainnya? 3
935 Apakah muntahnya berwarna kehitaman 1
seperti kopi atau berwarna merah segar 2
SEPERTI WARNA KOPI _____________________________
WARNA MERAH TERANG/DARAH _____________________
LAINNYA ………………………………………………………………………..
TIDAK TAHU _______________________________________
JUMLAH _______________________________
(SEBUTKAN)
C
dalam sehari?9 8
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
2
8
JIKA "YA"
937
ALMARHUM/AH MENINGGAL SAAT HAMIL, MELAHIRKAN, KEGUGURAN ATAU NIFAS :
B PERIKSA JAWABAN DARI PERTANYAAN 302 UNTUK JENIS KELAMIN ALMARHUM/AH : JIKA "LAKI-LAKI"
937 Apakah Almarhum/ah mengalami nyeri perut? 1
TIDAK TAHU ________________________________
933
933
937
946
939
939
KATEGORI KODE LANJUT KENO. PERTANYAAN
HARI ________________________________1
nyeri perut?
938 Berapa lama (hari/bulan) Almarhum/ah mengalami
BULAN ____________________________ 2
8
939 Apakah perut Almarhum/ah terlihat/ teraba 1
kembung/bengkak dan kencang? 2
9 89
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
TIDAK TAHU ______________________________
943
terlihat/teraba menggembung dan kencang?
940 Berapa lama (hari/bulan) perut Almarhum/ah
9 89
HARI ________________________________1
BULAN ____________________________ 2
TIDAK TAHU ______________________________
942 Apakah Almarhum/ah pernah mengalami 1
tidak BAB selama satu hari atau lebih? 2
bulan? TIDAK TAHU ________________________________ 8
941 Apakah proses terjadinya penggembungan perut 1
tersebut terjadi dalam hitungan hari atau hitungan BERTAHAP DALAM HITUNGAN BULAN ___________2
CEPAT DALAM HITUNGAN HARI
YA ______________________________________________
TIDAK ___________________________________________
8
943 Apakah ada benjolan di perut Almarhum/ah? 1
2
8TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
946
946
945 Di perut bagian mana terdapat benjolan 1
tersebut? 2
perut Almarhum/ah?
944 Berapa lama (hari/bulan) ada benjolan di
9 89
HARI ________________________________1
BULAN ____________________________ 2
TIDAK TAHU ______________________________
PERUT KANAN ATAS __________________________________
PERUT KIRI ATAS __________________________________
3
YA ______________________________________________
TIDAK ___________________________________________
kesulitan/kesukaran menelan makanan padat?
947 Berapa lama (hari/bulan) Almarhum/ah mengalami
8TIDAK TAHU ______________________________________
HARI ________________________________1
BULAN ____________________________ 2
PEERUT BAGIAN BAWAH __________________________
SELURUH PERUT __________________________________
TIDAK TAHU _______________________________________
948
948
4
8
950
948 Apakah Almarhum/ah merasa kesulitan 1
atau kesakitan ketika menelan makanan cair? 2
9 89
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
950 Apakah Almarhum/ah mengalami sakit kepala? 1
946 Apakah Almarhum/ah merasa kesulitan 1
atau kesakitan ketika menelan makanan padat? 2
TIDAK TAHU ______________________________
HARI ________________________________1
BULAN ____________________________ 2
TIDAK TAHU ______________________________
kesulitan/kesukaran menelan makanan cair?
8
8TIDAK TAHU ______________________________________
2
950
949 Berapa lama (hari/bulan) Almarhum/ah mengalami
9 89
YA ______________________________________________
TIDAK ___________________________________________ 953
953
943
KATEGORI KODE LANJUT KENO. PERTANYAAN
BULAN ____________________________ 2
YA ______________________________________________
TIBA-TIBA _________________________________________
CEPAT DALAM SEHARI ____________________________
PERLAHAN BEBERAPA HARI _______________________
TIDAK TAHU ___________________________________
sakit kepala?
951 Berapa lama (hari/bulan) Almarhum/ah mengalami HARI ________________________________1
BULAN ____________________________ 2
8
952 Apakah sakit kepalanya berat? 1
2
9 89
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
TIDAK TAHU ______________________________
954 Berapa lama (hari/bulan) Almarhum/ah mengalami
kaku kuduk pada leher?
8
953 Apakah Almarhum/ah mengalami kaku 1
kuduk pada leher? 2
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
HARI ________________________________1
BULAN ____________________________ 2
955
955
8
955 Apakah Almarhum/ah mengalami 1
gangguan mental? 2
9 89
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
gangguan mental?
956 Berapa lama (hari/bulan) Almarhum/ah mengalami
TIDAK TAHU ______________________________
HARI ________________________________1
BULAN ____________________________ 2
958
958
penurunan kesadaran atau tidak memberikan reaksi?
959 Berapa lama (hari/bulan) Almarhum/ah mengalami
kesadaran atau tidak memberikan reaksi? 2
8
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
9 89
8
958 Apakah Almarhum/ah mengalami penurunan 1
perlahan dalam beberapa hari? 3
957 Apakah gangguan mental yang dialami timbul 1
secara tiba-tiba atau cepat dalam sehari atau 2
1
BULAN ____________________________ 2
perlahan dalam beberapa hari? 3
960 Apakah proses penurunan kesadaran terjadi 1
secara tiba-tiba, cepat dalam sehari atau 2
9 89
kejang? 2
8
8
961 Apakah Almarhum/ah mengalami 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
TIBA-TIBA _________________________________________
CEPAT DALAM SEHARI ____________________________
PERLAHAN BEBERAPA HARI _______________________
TIDAK TAHU ___________________________________
TIDAK TAHU ______________________________
963 Apakah Almarhum/ah pernah mengalami tidak 1
dapat membuka mulut (trismus)? 2
kejang?
962 Berapa lama (hari/bulan) Almarhum/ah mengalami
9 89
YA ______________________________________________
TIDAK ___________________________________________
1HARI ________________________________
TIDAK TAHU ______________________________
8TIDAK TAHU ______________________________________
TIDAK TAHU ______________________________
HARI ________________________________
961
961
963
963
965
965
KATEGORI KODE LANJUT KENO. PERTANYAAN
89TIDAK TAHU ______________________________
8
tidak dapat membuka mulut?
964 Berapa lama (hari/bulan) Almarhum/ah mengalami
8
965 Apakah Almarhum/ah mengalami kaku pada 1
seluruh tubuhnya? 2
9 89
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
BULAN ____________________________ 2
TIDAK TAHU ______________________________
967 Apakah Almarhum/ah mengalami kelumpuhan 1
pada salah satu sisi tubuhnya? 2
kaku pada seluruh tubuhnya?
966 Berapa lama (hari/bulan) Almarhum/ah mengalami
9 89
YA ______________________________________________
TIDAK ___________________________________________
HARI ________________________________1
BULAN ____________________________ 2
TIDAK TAHU ______________________________
kelumpuhan pada salah satu sisi tubuhnya?
968 Berapa lama (hari/bulan) Almarhum/ah mengalami
8TIDAK TAHU ______________________________________
perlahan dalam beberapa hari? 3
969 Apakah kelumpuhan tersebut timbul 1
secara tiba-tiba, cepat dalam sehari atau 2
9 89TIDAK TAHU ______________________________
CEPAT DALAM SEHARI ____________________________
PERLAHAN BEBERAPA HARI _______________________
TIBA-TIBA _________________________________________
BULAN ____________________________ 2
pada tungkai kakinya? 2
8
8
970 Apakah Almarhum/ah mengalami kelumpuhan 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
TIDAK TAHU ___________________________________
kelumpuhan pada tungkai kaki?
971 Berapa lama (hari/bulan) Almarhum/ah mengalami HARI ________________________________1
BULAN ____________________________ 2
973
973
973 Apakah ada perubahan warna air seni pada 1
perlahan dalam beberapa hari? 3
972 Apakah kelumpuhan tersebut timbul 1
secara tiba-tiba, cepat dalam sehari atau 2
YA ______________________________________________
TIBA-TIBA _________________________________________
CEPAT DALAM SEHARI ____________________________
PERLAHAN BEBERAPA HARI _______________________
TIDAK TAHU ___________________________________
perubahan warna pada air seni?
974 Berapa lama (hari/bulan) Almarhum/ah mengalami
Almarhum/ah? 2
8
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
HARI ________________________________1
BULAN ____________________________ 2
975
975
8
975 Selama sakit terakhirnya apakah pada Almarhum/ah 1
pernah terlihat ada darah dalam air seninya? 2
9 89
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
TIDAK TAHU ______________________________
977
977
ada darah pada air seni?
976 Berapa lama (hari/bulan) Almarhum/ah mengalami
9 89
HARI ________________________________1
BULAN ____________________________ 2
TIDAK TAHU ______________________________
HARI ________________________________1
9
HARI ________________________________1
967
967
970
970
KATEGORI KODE LANJUT KENO. PERTANYAAN
TIDAK TAHU ______________________________
TERLALU BANYAK _________________________________
TERLALU SEDIKIT _________________________________
TIDAK ADA SAMA SEKALI ________________________
TIDAK TAHU ___________________________________
RUAM CAMPAK _________________________________________
RUAM BERISI CAIRAN BENING _____________________
HARI ________________________________
8
(sebutkan) ..........................................................................
BULAN ____________________________ 2
977 Apakah ada perubahan jumlah air seni yang 1
dikeluarkan Almarhum/ah dalam sehari? 2
YA ______________________________________________
TIDAK ___________________________________________
perubahan dalam jumlah air seni yang dikeluarkan
978 Berapa lama (hari/bulan) Almarhum/ah mengalami
8TIDAK TAHU ______________________________________
3
979 Berapa banyak jumlah air seni yang dikeluarkan 1
Almarhum/ah dalam sehari? 2
9 89
HARI ________________________________1
BULAN ____________________________ 2
TIDAK TAHU ______________________________
apakah Alamarhum/ah menderita bintik-bintik 2
merah (ruam) di kulit? 8
8
980 Selama sakit yang menyebabkan kematiannya, 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
982 Dimana lokasi bintik-bintik merah tersebut? Y T TT
bintik-bintik merah (ruam) di kulit?9 8
981 Berapa lama (hari) Almarhum/ah mengalami HARI ____________________________________
TIDAK TAHU ______________________________
4 Bagian tubuh lainnya 1 2 8
3 Tangan dan kaki? 1 2
8
2 Badan? 1 2 8
1 Muka? 1 21. MUKA
2. BADAN
3. TANGAN DAN KAKI
3. TEMPAT LAINNYA
983 Seperti apa bentuk bintik-bintik merah (ruam) 1
RUAM BERISI PUS (NANAH) ________________________
2
8
8
984 Apakah Almarhum/ah mengalami mata merah? 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
TIDAK TAHU ___________________________________
8
985 Apakah ada perdarahan keluar dari hidung, 1
mulut atau anus? 2
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
tersebut? 2
3
8
987 Apakah Almarhum/ah mengalami 1
penurunan berat badan? 2
8TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
986 Apakah Almarhum/ah pernah mengalami 1
herpes zoster/cacar monyet/lilitan? 2
penurunan berat badan?
987,1 Berapa lama (hari/bulan) Almarhum/ah mengalami
9 89
8
987,2 Apakah Almarhum/ah terlihat sangat kurus? 1
2
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
1
980
980
984
984
988
988
KATEGORI KODE LANJUT KENO. PERTANYAAN
HARI ________________________________1
HARI ________________________________1
BULAN ____________________________
8
1 2 8
1 2 8
T TT
988 Apakah ada luka/bercak putih di lidah atau 1
mulut Almarhum/ah? 2
YA ______________________________________________
TIDAK ___________________________________________
luka/bercak putih pada lidah atau mulut?
988,1 Berapa lama (hari/bulan) Almarhum/ah mengalami
8TIDAK TAHU ______________________________________
BULAN ____________________________ 2
8
989 Apakah terjadi pembengkakan pada bagian tubuh 1
Almarhum/ah? 2
9 89
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
TIDAK TAHU ______________________________
989,2 Dimana lokasi pembengkakan tersebut?
pembengkakan tersebut?
989,1 Berapa lama Almarhum/ah mengalami
9 89
HARI ________________________________1
BULAN ____________________________ 2
TIDAK TAHU ______________________________
Y T TT
4 Seluruh tubuh?
3 Pergelangan kaki?
2 Sendi?
1 Muka?
getah bening (kelenjar leher, ketiak, sela paha) 2
Almarhum/ah? 8
1 2 8
1 2 8
1. MUKA
2. SENDI
3. PERGELANGAN KAKI
4. SELURUH TUBUH
5. TEMPAT LAIN
1 2
990 Apakah ada benjolan kelenjar getah bening 1
5 Tempat lain?
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
1 2 8
990,2 Dimana lokasi benjolan kelenjar getah bening tersebut?
benjolan kelenjar getah bening tersebut?
990,1 Berapa lama (hari/bulan) Almarhum/ah mengalami
9 89
HARI ________________________________1
BULAN ____________________________ 2
(sebutkan) ..........................................................................
Y
4 Tempat Lain?
3 Selangkangan?
2 Ketiak?
1 Leher?
berubah menjadi kuning? 2
8
991 Apakah bagian putih mata Almarhum/ah 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
1 2 8
1 2
(sebutkan) ..........................................................................
1. LEHER
2. KETIAK
3. SELANGKANGAN
992 Apakah Almarhum/ah kelihatan pucat (lemah/ 1
kurang darah) atau terlihat pucat pada telapak 2
Almarhum/ah menjadi kuning?
991,1 Berapa lama (hari/bulan) bagian putih mata
9 89
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________
2
terlihat pucat?
992,1 Berapa lama (hari/bulan) Almarhum/ah
tangan, mata atau bantalan kukunya? 8TIDAK TAHU ______________________________________
9 89
HARI ________________________________1
BULAN ____________________________
TIDAK TAHU ______________________________
8
1 2 8
2
TIDAK TAHU ______________________________
4. TEMPAT LAIN
989
989
990
990
991
991
992
992
993
993
KATEGORI KODE LANJUT KENO. PERTANYAAN
Y T TT
8
Y
3. Puskesmas? 8
1 2 8
Klinik Swasta? 1 2 86. RS Swasta? 1 2
1 24. RS Pemerintah? 15. 6. RS SWASTA
T
2
7. APOTIK, TOKO OBAT, WARUNG 8
2
TT
1 2 8
2
8
1
pemberian cairan melalui infus?
1 Rehidrasi oral (minum oralit) dan atau
1
penyebab kematiannya? 2
4. PENGOBATAN LAINNYA
8
993 Apakah terdapat borok atau bisul besar atau 1
luka pada tubuh Almarhum/ah? 2
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
993,2 Dimanakah letak luka/bisul/borok tersebut?
10. PENGOBATAN DAN PELAYANAN KESEHATAN PADA EPISODE SAKIT TERAKHIR
borok atau bisul besar atau luka pada tubuhnya?
993,1 Berapa lama (hari/bulan) Almarhum/ah mengalami
9 89
(sebutkan) ............................................................................
...................................................................................................................
HARI ________________________________1
BULAN ____________________________ 2
TIDAK TAHU ______________________________
yang menyebabkannya meninggal?
SALIN RESEP/CATATAN KUITANSI JIKA ADA
1002 Sebutkan jenis obat (pengobatan) apa saja yang
diberikan kepada Almarhum/ah untuk penyakit
8
1001 Apakah Almarhum/ah mendapat pengobatan 1
untuk penyakit terakhirnya sebelum meninggal? 2
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
8. Tempat Lain?1 8
9 8
JUMLAH PERIKSA
TIDAK TAHU
YA ______________________________________________
TIDAK ___________________________________________
(sebutkan) ..........................................................................
8. TEMPAT LAINNYA7. Apotik, Toko Obat, Warung?
1003 Jenis pengobatan apa saja yang diterima?
1004
yang dipasang melalui hidung (NGT)?
4 Jenis pengobatan lainnya?
Dimana saja Almarhum/ah mendapat pengobatan
3 Pemberian makanan/obat dengan selang
2 Transfusi darah?
2. Pengobatan Tradisional?
1. Rumah?
untuk sakit yang menyebabkannya meninggal?
1006 Apakah petugas kesehatan menjelaskan penyakit/
1007 Apa yang dijelaskan oleh petugas kesehatan
tentang penyakit/penyebab kematiannya?
8
............................................................................
……………………………………………………………………………………
............................................................................
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
pernah mendapatkan pelayanan oleh petugas
kesehatan?
1005 Sebelum meninggal, berapa kali Almarhum/ah
8TIDAK TAHU ______________________________________
1008 Apakah Almarhum/ah menjalani operasi 1
untuk pengobatan penyakitnya? 2
(sebutkan) ..........................................................................
1. RUMAH
2. PENGOBATAN TRADISIONAL
3. PUSKESMAS
4. RS PEMERINTAH
5. KLINIK SWASTA
1 2 8
1 2 8
1 2 8
1. ORALIT/INFUS CAIRAN
2. TRANSFUSI DARAH
3. NGT
1 2 8
1008
1008
1008
1008
1101
1101
1001
1001
KATEGORI KODE LANJUT KENO. PERTANYAAN
8
SETIAP HARI ___________________________________
SEMINGGU SEKALI ___________________________________
KADANG-KADANG ____________________________________
TIDAK TAHU _________________________________________
operasi tersebut dilakukan?
8
TIDAK TAHU ___________________ 9 8
1009 Berapa lama (hari) sebelum meninggal HARI __________________________
8TULIS "00" JIKA KURANG DARI SATU TAHUN
1102 Berapa lama (tahun) Almarhum/ah sudah melakukan TAHUN
8
3
6
1010 Bagian tubuh mana yang dioperasi? 1
2
PERUT _________________________________________
LAINNYA ............................................................................
TIDAK TAHU
KEPALA _______________________________________
peminum alkohol? 2
DADA _________________________________________
(sebutkan)
TULIS "00" JIKA KURANG DARI SATU BULAN
1105 Berapa lama (bulan) sebelum meninggal Almarhum/ah BULAN
YA ______________________________________________
TIDAK ___________________________________________
11. FAKTOR RESIKO
1101 Apakah Almarhum/ah semasa hidupnya seorang 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
3
1103 Seberapa sering Almarhum/ah minum alkohol? 1
2
kebiasaan minum alkohol?TIDAK TAHU 9
8TIDAK TAHU ______________________________________
minum alkohol? 2
8
TIDAK TAHU 9
1104 Apakah Almarhum/ah sudah berhenti 1YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
1106 Apakah Almarhum/ah pernah merokok selama 1
hidupnya? 2
berhenti minum alkohol?TIDAK TAHU 9 8
1108 Seberapa sering Almarhum/ah merokok? 1
2
SETIAP HARI ___________________________________
SEMINGGU SEKALI ___________________________________
KADANG-KADANG ____________________________________
TIDAK TAHU _________________________________________8
8TULIS "00" JIKA KURANG DARI SATU TAHUN
1107 Sudah berapa lama (tahun) Almarhum/ah merokok? TAHUN
8
1110 Apakah Almarhum/ah sudah berhenti merokok? 1
2
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
1109 Berapa batang rokok yang dikonsumsi BATANG ROKOK
3
1111 Berapa lama (bulan) sebelum meninggal BULAN
Almarhum/ah berhenti merokok?TIDAK TAHU 9 8
TULIS "00" JIKA KURANG DARI SATU BULAN
Almarhum/ah dalam sehari?TIDAK TAHU ___________________ 9 8
1106
1106
1106
1106
1201
1201
1201
1201
1201
1201
1201
KATEGORI KODE LANJUT KENO. PERTANYAAN
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
YA ______________________________________________
TIDAK ___________________________________________
TIDAK TAHU ______________________________________
2
dan Catatan Sipil?
8
8
1
1204 (Bolehkan saya melihat akte kematian tersebut?)TANGGAL BULAN TAHUN
SALIN TANGGAL, BULAN, DAN TAHUN
DIKELUARKANNYA AKTE KEMATIAN?
1202 (Bolehkan saya melihat surat keterangan kematian tersebut?)
1203 Apakah Almarhum/ah memiliki Akte Kematian
yang dikeluarkan oleh Kantor Dinas Kependudukan
Surat Keterangan Kematian? 2
DARI SURAT KETERANGAN KEMATIAN
12. DATA YANG TERTULIS DARI SURAT KETERANGAN KEMATIAN
1201 Apakah Almarhum/ah mempunyai 1
TANGGAL BULAN TAHUNSALIN TANGGAL, BULAN, DAN TAHUN KEMATIAN
DUA) DAN CATAT TANGGAL KETERANGAN MEDIS TERSEBUT (CATAT INFORMASI MENGENAI ALMARHUM/AH)
MENIT
13. KETERANGAN PENDUKUNG DARI CATATAN KESEHATAN LAINNYA
1301 Apakah ada keterangan kesehatan pendukung 1
lainnya? 2
1302 SALINLAH SEMUA KETERANGAN MEDIS YANG MENDUKUNG DARI DUA PELAYANAN KESEHATAN TERAKHIR (JIKA LEBIH DARI
HASIL VISUM TERSEBUT)
..........................................................................................................................................................................................................................................
1203
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..................................................................................................................................................................................................................................................................
YA _______________________________________________
TIDAK ___________________________________________
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
1303 SURAT IZIN PENGUBURAN (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM SURAT TERSEBUT)
..........................................................................................................................................................................................................................................
1304 HASIL PEMERIKSAAN VISUM/AUTOPSY FORENSIK (JIKA ADA, SALINLAH PENYEBAB KEMATIAN YANG TERCANTUM DALAM
CATATAN PEWAWANCARA
DIISI SETELAH WAWANCARA SELESAI
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1305 CATATAN WAKTU AKHIR WAWANCARA JAM
1203
1301
1301
1305
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14. RESUME DAN DIAGNOSA (Dibuat oleh Dokter)
RESUME AUTOPSI VERBAL : ..........................................................................................................................................................................................................................................
NAMA DOKTER : ..........................................................................................................................................................................................................................................
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TANDA TANGAN DOKTER : .....................................................................................................
TANGGAL DIAGNOSIS :.....................................................................................................
NAMA DOKTER :.....................................................................................................
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disebabkan oleh
d.
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II. PENYAKIT/KONDISI LAIN YANG BERKONTRIBUSI
NAMUN TIDAK BERHUBUNGAN DENGAN I a-d
disebabkan oleh
c.
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disebabkan oleh
b.
....................................................................................................................................................................
a.
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I. PENYEBAB KEMATIAN MENURUT DOKTER PUSKESMAS SELANG WAKTU MULAI TERJADINYA PENYAKIT SAMPAI MENINGGAL
THN BLN HARI JAM ICD -10
Propinsi Kab/Kota Kecamatan Kel/Desa No. Urut Kasus
ID/NOMOR REFERENSI KONTROL
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