Various government programs are unable to reduce the number of maternal deaths. Medical personnel in remote areas are still far from adequate. In some areas, a breakthrough has been made through a traditional-modern midwives partnership program which produces significantly positive results. What are the main health problems of women at childbirth, particularly in eastern Indonesia? Tempo English Edition reports from East Nusa Tenggara and South Sulawesi.
ONE night in Bikolan hamlet, Kolhua village, on the outskirts of the town of Kupang, a woman, Dorkas Bistole, was fighting for her life when giving birth to her fifth child. The placenta was left in the uterus (retensio placenta), that is, the baby had been born but the placenta was stuck in her womb. The dukun (traditional midwife) who assisted the labor was unable to bring out the placenta. And Dorkas needed medical help as there was post-natal bleeding.
What could they do? Bikolan does not have a midwife. The auxiliary Community Health Center (Puskesmas) in the nearest village was 5 kilometers away. With the roads in a potholed and poor condition, Daud Kase, Dorkas’s husband, had trouble transporting his wife by public transportation. So Daud chose to walk and carry his wife to the Puskesmas. Residents helped carry the newborn baby. “The cost could reach Rp300,000 to hire a vehicle at night. In the daytime, the cost could drop to Rp100,000,” said Daud to Johannes Seo of Tempo on Friday last week.
Fortunately Dorkas quickly received medical assistance. Many women experience complications and cannot be saved in the hands of a traditional midwife in remote areas. The case of placenta left in the womb is often faced by Rabiah who is known as the “Floating Nurse” in the subdistrict of Liukang Tengaya, Pangkep regency, South Sulawesi. The nurse who works in the subdistrict of 25 islands often loses her patients who experience problems during childbirth because of transportation constraints.
The experiences of Floating Nurse Rabiah are just one of a series of stories indicating the great number of maternal deaths in Indonesia. Data of the Health Department’s Research & Development Board indicates that maternal death rates (AKI) are 228 per 100,000 births. This is the highest AKI in Southeast Asia and even in Asia. The Millennium Development Goals (MDGs) set maternal death rates in Indonesia by 2015 at 108 per 100,000 births. The MDGs constitute global development targets approved by 189 of the United Nations member states in 2000.
The eight targets determined include the eradication of poverty, the reduction of infant mortality, and the promotion of maternal health. The fifth target of the MDGs is closely connected with the reduction of maternal deaths rates which are targeted at 108 per 100,000 births by 2015. According to many circles-among them the result of the Women’s Research Institute (WRI) survey-this target will not be achieved. In the words of the National Development Planning Board (Bappenas), the maternal health target-including the reduction of maternal death rates-is still off-track. Meanwhile other targets are already on track. According to Bappenas, the most they can achieve by 2015 is that AKI is reduced to only 163 per 100,000 childbirths. And the government is considered to have failed in improving maternal health since death rates are still high.
Professor Saparinah Sadli, 83, an expert on women’s affairs and a leading female figure in Indonesia, outlines a number of crux problems, including the health of women in labor, in her book Berbeda tapi Setara (Different but Equal). Launched on April 21, Sap-as she is fondly called-writes about the need for attention to women’s lives and for the reduced number of maternal deaths so that the MDGs can become achievable.
Actually Sap wrote about AKI in her book six years ago. According to her, the figures mentioned by the government with regard to maternal deaths are still debatable among experts. Some estimate that the actual figure exceeds that announced by the government. In fact, the WRI in its survey records the current number of maternal deaths at still 307 per 100,000 childbirths, which is way above the figure of the Health Department.
To think that in order to reduce the number of AKI thus far, the Health Department has organized a number of programs, among which are Essential Reproduction Health Services, Love Mother Movement, Vigilance Villages, Village Maternity Ward (Polindes) and Integrated Health Service Posts (Posyandu). But all these do not seem to be able to lower the number of maternal deaths. According to Sap, these conditions are caused by the fact that AKI problems are not only the responsibility of the Health Department. Other government agencies have not noted the link of gender perspectives in the development projects. For example, the results of a survey show that the villages which do not have roads have relatively higher rates of maternal deaths.
“In my view, actually the MDGs have women’s values with gender perspectives. All the indicators should promote the conditions of women’s lives,” says Sap. Therefore, according to her, in order to promote maternal health there is need for values, attitudes and behavior which do not discriminate against women’s rights. Thus it is important to integrate the perspective of gender into all large-scale development programs.
Sociocultural factors are also one of the reasons that cause the poor health condition of many women in Indonesia. Quoting Saparinah’s words, women, despite their pregnancy, continue to work the hardest in the family, they eat last, go to bed the latest, and get up the earliest. Therefore, many are affected by anemia thus causing high-risk problems during childbirth.
The provinces with the largest number of maternal health problems to date are in the eastern part of Indonesia (see infographic). In Papua, the existence of nursing academies greatly helps reduce the rates of maternal deaths. The Diploma I Program of the Maternity and Nursing Academy in Nabire regency last March graduated 50 students. Meaning there are more midwives who constitute the spearhead of women’s health services in the field.
These midwives will be assigned to remote areas in Papua’s harsh geography. In addition to Nabire, the Diploma I Program is also held in the regencies of Biak, Jayapura, and Timika. To deepen the study of maternity, the graduates of the nursing school must undergo a one-year study course.
Nonetheless, there is still a limited number of midwives and nurses for rural health services in isolated areas. In fact, many areas do not have midwives. Midwives and health personnel in Papua, for instance, are only 1,000 in number, assisted by Posyandu staff. Throughout Papua there are 3,300 villages which still offer a wide opportunity to become a midwife. The trouble is that people are not interested in the profession because of the distant isolated fields they have to visit in performing their duties. Reportedly the midwives in remote areas need to wear sturdy shoes and have strong legs and with enormous
endurance abilities. There is a desperate need for more highly dedicated persons like Rabiah so that the high rates of maternity deaths can be tamed.
On the other hand, many people in many places in Indonesia still rely on traditional childbirths aided by a traditional midwife. Childbirths assisted by health personnel in Indonesia today are estimated at some 70 percent, and 55.3 percent by traditional midwives. WRI research also records that 30 percent of national childbirths are still administered by traditional midwives.
Why do people prefer traditional midwives and their traditional methods? Because the fee is low and can be paid with agricultural produce or other goods. It is easier to find traditional midwives and they are regarded as willing to provide private services. In fact, Mama Taroci Muda, a traditional midwife in the village of Putek, in the town of Kupang, will provide free childbirth assistance, and every woman she has helped has survived. “I gave birth to five children without the help of a [modern] midwife or a nurse. I was helped only by a traditional midwife and the women here. But I was all right,”
the leading female figure of Petuk village, Simon Niab, told Tempo.
The point is, not every region has such a figure as Mama Taroci, let alone a midwife as competent as Rabiah, the Floating Nurse.
— Farida Senjaja, Sadika Hamid, Agustina Hariati (Jakarta), Johannes Seo (Kupang)
Source: Tempo Magazine, No. 36/X, May 05-11, 2010