Indonesia isn’t safe for pregnant women. In 2010 almost 10,000 Indonesians lost their lives giving birth. The ratio is at least 228 deaths per 100,000 live births. It used to be much worse – 20 years earlier the figure was three times higher. What chance has the nation of reaching its much publicised Millennium Development Goal of 102 by 2015? Duncan Graham reports:
Blond Noelle is the ideal pregnant patient. She lies naked and unembarrassed with her mouth open and legs apart while two nervous gloved and gowned teenagers tend to her intimate needs.
Monitors check her blood pressure and the foetal heart beat. Colored lines snake across screens. A technician fine-tunes the equipment. Beep, beep, beep – every ear is tuned to a shift in tone or pace.
Slowly the baby appears followed by the placenta. It’s a girl! No, there’s too much confusion, a boy, little Hal. Yet no signs of joy from the mother who continues to stare at the ceiling. Nor does she get distressed when her newborn turns blue and needs resuscitation. Goodness, she didn’t even scream.
Nor will she, for Noelle S575 is a Rp 450 million (US$45,000) computer-controlled birth simulator, the first brought to Indonesia from the US and used in Malang’s largest midwife college, the Akademi Kebidanan Wiro Husada Nusantara.
Inside her plastic womb is a hydraulic pump that pushes baby through the birth canal. The system is so sophisticated that lecturers using WiFi can manipulate the procedure from a distance. They can create a breech birth, prolong delivery and add other complications, including haemorrhaging, one of the main reasons many women perish during delivery.
The college’s 1,200 student midwives (no men are accepted) only use Noelle when they’re less clumsy in the second year of their three year diploma course that includes attending at least 50 live births. Four year degree programs are also offered.
After a six month internship and getting national certification they head home, usually to villages in Nusa Tenggara, Kalimantan, Papua and other distant areas where professional colleagues and other medical support can often be far away.
Families spent around Rp 35 million (US$3,500) in course fees and living costs to get their daughters this far, but with more than 3.5 million babies born in Indonesia every year they’ll seldom be idle.
“One of our graduates is getting Rp 7 million (US$700) a month in a hospital (most get about a third of that salary), but others rely on the government’s Jampersal birth insurance program so mothers don’t pay,” said college director Donny Yunamawan.
“Midwives are supposed to get Rp 540,000 (US$54) for a delivery and some pre and post natal care.
“I hear that payments are often late and the sum can decrease as it passes through other hands. There’s a rumor that the figure will rise to Rp 700,000 (US$70) next year.”
Sunarsih Yudawati, 56, head of Ikatan Bidan Indonesia (IBI - Indonesian Midwives’ Union) in the Malang region and mother of two doctors, reckoned her members would be content with the higher sum paid in full.
She’s delivered about ten babies a month for the past 30 years. She said she’d never lost a mother and only two babies, one stillborn.
“There are about 200,000 midwives in Indonesia,” she said. “The need is for higher quality education at university level and higher payments. The other issue is educating families to accept professional support. This is best done through word of mouth.”
Registered midwives are not the only ones bringing the next generation into the world. A survey of Malang’s midwives by IBI found they were outnumbered by dukun, traditional birth attendants, untrained, uncertified but often the first to offer help in the villages.
Brawijaya mathematics department Professor Waego Hadi Nugroho, who started the midwifery college in 2007, said the dukun were a fact of Indonesian life that couldn’t be legislated away.
“Scholarships are sometimes given to help dukun become professional midwives,” he said. “I can’t deny they have a role so we teach our students how to collaborate.
“We also don’t have enough puskesmas (community health clinics). The government’s goal is two midwives for every village. That’s fine, but the policies don’t match.
“In an ideal situation midwives should develop a relationship with women when they get married. Good nutrition is important. So is family planning. Many girls give birth too young.
“Midwives need to be active and ensure early prenatal care. But even in Malang (East Java’s second biggest city) there are still pregnant women who hide from midwives.”
On the plus side Indonesia has yet to experience the litigation wave that’s swamped countries like the US and Australia with patients suing doctors and hospitals when things go wrong.
The result is that medical insurance premiums have risen steeply and some doctors have given up obstetrics for fear of litigation.
The Indonesian government’s previous policy was to train high school girls for a year and then send them into the regions. The maternal death rate fell, but not sufficiently. The data is confusing and elastic, but the World Health Organisation has boiled down its figures to produce a chilling ‘lifetime risk of maternal death’ category.
In Indonesia one in every 210 women of child bearing age faces a premature, awful and largely avoidable death. In Malaysia it’s one in 1300 and China one in 1700. By far the safest place to be a woman is Singapore where the ratio is one for every 25,300.
WHO groups Indonesia as one of the nations ‘making progress’. Clearly there’s some way to go.
Less than ten kilometers separate Malang city hall from the village of Buring where new Mom Kurniawati, 17,( right) lives the stark reality of Indonesian life, worlds apart from the offices of government workers shaping health policy.
She has never been to school and only speaks Madurese. Her baby Sekar Arum was born last month on a crude bed built of scrap timber. The new Indonesian’s first breath was polluted, her first view of her motherland a patched one-room lattice-wall shack.
Kurniawati lives together with her casual laborer husband Misle, whose age she doesn’t know, two elderly childless ‘aunts’ who adopted her and are often sick, and a sister.
Aunt Toen earns about Rp 15,000 (US$1.50) a day hawking bananas in the rich suburbs, well below the official poverty line. That’s the family’s income along with Misle’s earnings. The people are cheerful, the kids are wrapped in love, but the environment is vile.
Outside are two large piles of smoldering timber in a charcoal maker’s yard. The stench of toxic tars from burning garbage is inescapable. Inside the kitchen roof leaks through the plastic sheets used covering cracked tiles.
Kurniawati never attended the local puskesmas during her pregnancy even though consultations are free because her husband said ‘no’. She didn’t know why.
Instead the couple paid a local bidan (midwife) Rp 15,000 for a pre-birth check and Rp 200,000 (US$20) to attend the delivery. It’s unclear whether the woman was registered.
Commented Sunarsih Yudawati: “This situation is not unusual. The puskesmas staff need to get out and find the pregnant women, not wait for them to come.”
Sekar Arum’s birth only took an hour. There were no complications and the breast-fed baby girl looks fine, confirming village wisdom that fussy professionals aren’t needed in a natural process - making reform that much harder.
(First published in The Sunday Post, 3 March 2013)