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Ignorance, Lack of Funds Push Up Maternal Deaths

By Richel Dursin, IPS, 13 jun 2000

JAKARTA, Jun 13 (IPS) - Ignorance of antenatal care, coupled with poor health services, exacerbates maternal deaths in Indonesia, placing the country among nations with the highest maternal mortality ratio in Southeast Asia.

"The maternal mortality ratio in Indonesia is extremely high compared to other South-east Asian countries," says Victor Cole, health project officer of the United Nations Children's Fund (UNICEF) in Jakarta.

Latest data gathered by UNICEF show that for every 100,000 Indonesian women who give birth, about 450 of them die.

In other South-east Asian countries, the maternal mortality ratio or the annual number of deaths of women from pregnancy-related causes for every 100,000 live births is lower than Indonesia's. In Burma, this ratio is 230; Philippines, 170; Vietnam, 160; Thailand, 44; Malaysia, 39; and Singapore, six.

"Maternal mortality is still one of the biggest health problems in the country," says Azrul Azwar, director general of community health of the Ministry of Health.

For the past decade, the reduction of the country's maternal mortality ratio has been the priority of the Ministry of Health, but until now the number of maternal deaths remains high.

"Once the majority of births are attended by trained health personnel, the country's maternal mortality ratio will be automatically reduced," says Daradjat Natanagara, UNICEF programme coordinator.

In Indonesia, most births are attended by non-medical staff, including family members and traditional birth attendants, locally known as 'dukun bayi'.

"Even when the mothers undergo pregnancy check-ups four times in health centres, they go to the traditional birth attendants when it is time for them to give birth," Natanagara says.

"The traditional birth attendants do not know what to do when there are complications during deliveries, resulting in high maternal deaths," Cole says.

In every village in Indonesia, two or three traditional birth attendants supervise deliveries. Unlike trained health personnel, they are believed to have some supernatural powers, provide added services such as massage after birth, and accept small, delayed and barter payment in raw goods such as sugar or rice.

"The traditional birth attendants are very influential and accessible. In contrast, the trained health personnel do not easily develop rapport with the communities," Cole says.

Most Indonesian women also prefer the traditional birth attendants because they meet emotional, spiritual, and cultural needs by incorporating prayers and herbs into the deliveries, which are seen as part of the normal birth ritual.

At present, UNICEF no longer trains the traditional birth attendants. But aware of their value to local communities, it is trying to get them work closely with the village midwives and using them to mobilise people, especially the pregnant women to use health facilities.

"We do not want to encourage the people to go to the traditional birth attendants by training them, but we can use them to change the attitude of the people," Natanagara says.

"There is no way the traditional birth attendants can handle any of the complications during deliveries. Even training them will not have an impact on reducing maternal mortality, but it does not mean that we have to discard them. We still need them because they are well-respected in the communities," Cole adds.

Most Indonesian women, especially in the rural areas also still prefer to give birth at home, which is generally considered the safest place to deliver. Many also adhere to the traditional belief that labour places a woman in a life and death situation and that the "forces' which keep a woman on the side of life are strongest in the home.

It is also due to practicality and affordability -- giving birth at home allows the family to be present.

"Since most women prefer to deliver at home, it follows that majority of obstetric complications will be encountered in the home rather than in a health facility," Azwar says.

Besides, there are not enough village midwives who can attend to the pregnant women, according to Adrianus Tandjung, head of the reproductive health service division of the non-governmental Indonesian Planned Parenthood Association.

"Many village midwives do not actually live in the houses provided by the government in the villages they serve because of the social and economic conditions in the villages. They stay in the cities," Tandjung explains.

The Ministry of Health assigns one midwife for every village in Indonesia to provide not only maternity care, but also attend to diseases like diarrhoea.

"There is a lack of health personnel and facilities, especially in the remote areas due to insufficient funding support from the government," Azwar says, adding that the economic crisis has worsened the substandard maternal care in the villages.

As a result of the financial turmoil in 1997, more people went back to the villages, where health centres are inaccessible, and the daily average expenditure went down to 5,000 rupiah (60 U.S. cents) among poor families.

Among the 26 provinces in Indonesia, maternal mortality is high in East Nusa Tenggara, West Nusa Tenggara, and Irian Jaya, where the people are poor and strongly believe in traditional birth attendants.

The health ministry points out that the principal medical causes of maternal deaths in Indonesia are haemorrhage, eclampsia, and abortion complications.

Under the Indonesian Health Law No 23 issued in 1992, abortion is illegal except when the mother's life is at risk. Based on the law, legal abortions are primarily conducted in government hospitals by an obstetrician-gynaecologist with strict supervision by a special medical team.

When legal abortions are not possible, Indonesian women seek a variety of methods to terminate their unwanted pregnancies, including the consumption of traditional herbs. The government estimates that 15 to 20 percent of the maternal mortality ratio is attributable to abortion.

Non-medical causes of maternal deaths include delays in seeking care, reaching a medical facility, and receiving appropriate emergency obstetric care.

"A danger sign is sometimes not seen as a danger, but as a routine inconvenience of pregnancy, until it is too late," Azwar says. "Dangerous delays may occur because women tend to sacrifice by enduring pain for a long time before requesting help and because such bravery is valued by the community."

The Ministry of Health has also found out that women work longer hours, which can hurt their health. In the rural areas, women are most likely to carry the same amount of workload whether pregnant or not.

"Working during pregnancy is associated with good luck, exercise and feeling healthy. Reducing work is also imposing a financial burden on the family," Azwar says.

The close spacing of pregnancies also contributes to maternal deaths. A new pregnancy within two years of a birth can reduce a mother's physical resilience, hurt her nutritional status and cause increased vulnerability to chronic illnesses, thus boosting the risk of maternal mortality.

About 15.4 percent of pregnant Indonesian women still have closely spaced pregnancies despite the government's campaign for birth spacing of five years.

Dietary taboos are another socio-cultural factor that also causes maternal deaths. Women in traditional Indonesian communities have a long list of prohibited food, which is expanded during pregnancy, due to concerns about malodorous blood and breast milk and impact on the newborn.

"Many pregnant mothers do not consume high-protein foods because their dietary taboo includes not eating meat, fish and eggs," Azwar explains. Pregnant women are also prohibited to drink coffee, which is believed to cause a baby to have dark skin, and ice water, presumed to make a baby's head big.

Likewise, in some communities, maternal deaths are considered as God's choice or acts of martyrdom. Says Natanagara: "The orthodox Muslims, including the ulemas or the religious leaders believe that if a woman dies while delivering a baby, she goes straight to heaven."

Thus, curbing Indonesia's high maternal mortality rate is as much as social concern as it is a health one. "Unless the attitude of the people are changed, reducing maternal mortality will not be accomplished," observes Natanagara. (END/IPS/ap-he-pr/rd/js/00)

Origin: Rome/INDONESIA/

---- [c] 2000, InterPress Third World News Agency (IPS)
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