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A matter of life and death

  • Rita A. Widiadana

    The Jakarta Post

| Wed, January 13 2010 | 11:25 am
A matter of  life and death

Real story: A doctor examines her patient at a clinic for women’s reproductive health in Badung market, Denpasar. Thousands of women in Indonesia die annually due to complications related to pregnancy and childbirth. JP/Zul Trio Anggono

The United Nations Population Fund (UNFPA) and Asian Forum of Parliamentarians on Population and Development (AFPPD) recently met in Bali to find ways to improve the poor health condition of the majority of  women in Indonesia and Asia-Pacific countries. Indonesia is among the 11 countries that contribute 65 percent of world maternal deaths. The Jakarta Post’s Rita A. Widiadana compiled the reports in the following articles.  

Choirunissa, 38, was nine months pregnant. She was also poor, malnourished and anemic.

The expectant mother — also known as Nissa — already had five children prior to her sixth pregnancy and did not want another baby.

When her due date arrived, her husband Lukman called a traditional birth attendant to help his wife deliver the baby at their modest home in a remote village in Jember, East Java.

During the delivery, Nissa started bleeding but the birth attendant did not recognize the seriousness of the problem until she collapsed.

Lukman decided to take her to a nearby hospital but he had no money and no transportation. He finally he got a loan from a neighbor and took her to the hospital only to find that the medical staff could not save either mother or baby.

Thousands of women in Indonesia stretching from the western-most Nanggroe Aceh Darussalam to eastern Papua provinces share Nissa’s sad story — they died due to complications related to pregnancy and childbirth.

The majority of Indonesian women living in rural areas delivered their babies at home, about six in
every 10 births.

Many families prefer to use a dukun (traditional healer or shaman) because of traditional beliefs and because it is cheaper than using a trained midwife or going to the hospital. These traditional birth attendants usually perform household chores while the mother recovers.

In many rural areas in Indonesia, traditional ways of delivering babies still exist.

Village women in Papua are aided by traditional midwives in the middle of lust tropical forests. The local midwife usually uses bamboo fibers to cut the umbilical cord and wipe the newborn babies with guava leaves.

The delivery instruments used are certainly not sterile and can lead to serious infection.

The traditional midwife may not be able to deal with complications during child labor and by the time the mother gets to a local clinic, it may be too late. As a result, according to Health Ministry data, the country’s maternal mortality rate (MMR) remains high at 307 maternal deaths per 100,000 live births, with about two women dying every hour during pregnancy and delivery.

In comparison, the maternal mortality rate reached only 39 per 100,000 in Malaysia and 6 per 100,000 in Singapore.

The main cause of maternal death in Indonesia is bleeding (28 percent of maternal death), followed by pre- and post-eclampsia ( 24percent ), infection (11 percent), and the complications of abortion (8 percent) and prolonged labor (5 percent). Most of these deaths occur with births handled by traditional birth attendants rather than by medically trained healthcare professionals.

Dr. Saramma Thomas Mathai, United Nation for Population Affairs (UNFPA) Asia-Pacific Regional Office, said that maternal mortality is an indicator of gross inequality, human rights abuse and development failure.

“It is clear that when a woman in most of Asia becomes pregnant, her survival cannot be assured.

“All maternal health problems are preventable as long as the government pays attention and prioritizes maternal health.”

Of the 11 countries that contribute to 65 percent to global maternal death, five are in Asian countries including Indonesia, Bangladesh, Pakistan India and Afghanistan.

A high mortality rate is an indicator of the status of poor functioning of a country’s health system including lack of supportive and protective legal and policy environment, Mathai said.  

Dr. Sri Hermiyati, director of maternal health at the Health Ministry, admitted Indonesia still faces tough challenges in dealing with maternal health.

“Reducing the MMR has become the first priority in the Indonesian health care system. But we have to admit the roads are still very long and rough,” Hermiyati said.

Health matters: Hundreds of Bogor residents show up for mass health treatment jointly held by the administration and the World Health Organization in the West Java town. In many rural areas in Indonesia, many families prefer to go to a dukun or traditional healer because of traditional beliefs and cheaper.  JP/Theresia SufaHealth matters: Hundreds of Bogor residents show up for mass health treatment jointly held by the administration and the World Health Organization in the West Java town. In many rural areas in Indonesia, many families prefer to go to a dukun or traditional healer because of traditional beliefs and cheaper. JP/Theresia Sufa

Indonesia is in a danger of failing to achieve the Millennium Development Goals (MDGs) if it fails to cut its MMR, she pointed out.

Indonesia is among Asian countries that have a limited national health budget at only 2.4 percent of the state budget, far below the World Health Organization (WHO)’s standard of at least five percent of the state budget.

With an under-funded health sector, Indonesia is likely to face difficulties in reducing MMR by three quarters by the end of 2015.

Since early 1990s, the Indonesian government has actually launched a number of programs on
maternal health including Safe Motherhood, Making Pregnancy Safer (MPS), Gerakan Sayang Ibu (Mother-Friendly Movement), Alert Village and the National Health Insurance Scheme (Jamkesnas) for expectant mothers.

All of the programs aim to provide quality maternal health care including pre- and post-natal checkups, newborn health care and maternity saving plans in attempts to improve birth preparation and complication readiness imposed from national to the community level.

Dr. Sri Soemaryati, a legislator and former head of National Family Planning Program, was concerned that the programs would not reach regional levels.

“Indonesia’s health map is drastically changing. After decentralization, there is a wide disparity between provincial and regional levels in providing public health services, including maternal and child health.”

Indonesia covers 450 cities, municipalities and thousands of villages with huge disparities in health access and facilities.

Lack of priority and political will among regional administrations also worsens the public health sector.

Jeremy Shiffman, an expert from the Washington-based Central for Global Development, conducted a comprehensive study on the implementation on maternal health policy in five developing countries including Indonesia, India and Nigeria.

Shiffman’s study found out Safe Motherhood program, which was advocated under Indonesia’s
New Order president Soeharto between 1987 and 1997, was very effective in reducing the country’s
maternal mortality rate and child mortality rate.

“After his fall from political power, the program declined,” he said.

In Indonesia, he said, democratization and subsequent reform--including public sector decentralization may have hurt safe motherhood program.

Soeharto, using his authoritarian political infrastructures, had pushed regional governments to prioritize Safe Motherhood program as well as population control scheme such as National Family Planning Program.

Since his fall, political and financial power became decentralized to regional governments.

As a result, the capacity of the central government including the Health Ministry to command the district governments to prioritize maternal health care weakened dramatically.

According to a study by Ascorbat Gani, medical professor at the University of Indonesia, decentralization of health authority from central to provincial and regional governments has worsened the women and children’s health conditions.

The prevalence of disparities in Indonesia before and at the starting of the decentralization process was very extensive. In many remote regions such as Ende in East Nusa Tenggara, it was reported that only six out of 28 community health centers had a doctor each.

According to a report, there was one doctor or health promoter per 16,000 people and one public health worker handled 28,000 people.


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