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fforts to lift Indonesia'€™s economy to a higher level will depend a lot on the country'€™s ability to decrease the number of women dying from complications during pregnancy and labor. With a maternal mortality rate (MMR) of 359 deaths for every 100,000 live births, we failed to achieve the Millennium Development Goals'€™ target of reducing the rate to at most 102 deaths/100,000 live births last year.

Recent research by the Centre for Strategic International Studies (CSIS) in 10 regencies and municipalities of five provinces highlights the difficulties faced in trying to bring down the MMR in Indonesia, particularly in the research areas of Riau, Banten, East Java, East Nusa Tenggara (NTT) and Papua.

Regional autonomy, a lack of coordination and other factors contribute to the complexity of saving women'€™s lives.

Our study reveals that poor governance, particularly at the lower levels, contributes to stagnation in efforts to save more women.

The first problem is related to the rotation of agency officials. Governors, regents and mayors have discretion to move and replace civil servants.

Our study suggests that many programs fail to be effective because officials are easily transferred to other agencies, with tenures too brief to plan and implement the MMR programs.

New officials often have to start from zero in preparing programs. Offices have complained about a lack of well-qualified human resources to ensure good and sustainable programs.

The second problem is the designated structure of regional institutions. Because of regulations that limit administrative areas to 18 '€œlocal government working units'€ (SKPD), some agencies have had to merge into one.

For example, the establishment of local boards of '€œsocial empowerment, women and family planning'€ included elements of local administrations and the chapters of the National Family Planning Board.

For offices constrained by budget allocations, such mergers affect the priority and focus of agencies'€™ programs '€” on top of problems faced by the lack of human resources.

The third problem of poor governance is weak or non-existent coordination across sectors, as also witnessed in many other areas. Maternal deaths are obviously life-and-death emergencies, but even these are not exempt from pervasive ego-sectoral attitudes.

Many pregnant women still die due to the gross lack of physical access to medical facilities. The public works agencies should take responsibility in providing proper road infrastructure connecting the homes of the women with health centers.

However, in many cases, little attention is paid to this issue, as pregnant women are perceived as the sole responsibility of health agencies.

Awareness on the importance of allocating enough funds from local budgets to maintaining and improving the health of pregnant women is also lacking

The fourth problem relates to authority in the distribution of health workers. Regional autonomy limits both central and provincial government authority to push local governments to comply with minimum procedures, as part of efforts to decrease maternal mortality.

Local health centers, for example, need sufficient and well-trained doctors, midwives and nurses, medicines and equipment. Yet only a few areas have enough family-planning field staff, either due to limited funds or weak commitment on the part of local leaders.

Midwife academies have been mushrooming in recent years, but the number of qualified graduates is left wanting.

Some areas have abundant health professionals, but others face scarcities because the availability, distribution and income of health workers depends on the economic clout of an area. Low-paid doctors may therefore move to other areas.

Among local leaders, allocating funds for infrastructure development is considered more politically rewarding, since it is clearly visible to voters; unlike efforts to reduce the MMR, which take longer to yield results.

The CSIS study identified at least 19 obstacles to decreasing Indonesia'€™s MMR. Beyond poor governance, other factors relate to general poverty and a lack of knowledge on reproductive health.

The MMR issue faces the classic problem that high-quality data is contingent on the validity, measurement and mechanism of regular reporting of maternal mortality across all localities. The cause of death of pregnant women is often unclearly reported.

Furthermore, patriarchic structures still sometimes cause delays in patients seeking medical help. In the home, the woman'€™s inability to make major decisions leads to a waste of precious time on top of the lack of access to urgent medical treatment.

Apart from the dismissive attitude to '€œwomen issues'€ among officials, inequality is still evident in the family.

Nevertheless, several local government-sponsored innovations must be appreciated. These measures aim to speed up efforts to ensure a healthy pregnancy and safe delivery for as many women as possible.

They include the '€œflying, floating, barefoot'€ health services (terbang, terapung, kaki telanjang) by air, sea and land in Papua, the '€œRevolution of Mothers'€™ and Children'€™s Health'€ (Revolusi KIA) in East Nusa Tenggara), the 24-hour community health centers in Riau and the network of delivery rooms in hospitals (Jakabrusasu) in Surabaya. These innovations need to be continuously supported, monitored and evaluated.

Further efforts to save women'€™s lives in pregnancy and labor will depend on better relations between local executive and legislative branches, a strong commitment of local leaders and a stronger role of local development planning bodies, especially to establish effective coordination across sectors and between central and local authorities.

All of the factors in the web of complexity must be taken seriously and solved simultaneously to ensure safe delivery of healthy newborns by healthy mothers '€” and prevent deaths.
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The writer is an anthropologist and a senior researcher at the Centre for Strategic and International Studies. The above study was supported by the MAMPU program (Empowering Indonesian Women for Poverty Reduction) and Australian Aid.