Maternal Death Rate Tough to Reduce

The Indonesian Observer
Sunday “Focus” Section, page 3
April 12, 1998

Every year some 20,000 women in Indonesia die from complications of pregnancy and childbirth. Turning the situation around is tough, but efforts underway appear to be on the right track. D.L. Parsell takes a look for The Sunday Observer.

One of the biggest public health success stories in Indonesia in recent years is a dramatic reduction in the number of infant deaths. Since 1967, infant mortality has declined by 60 percent, according to the Indonesian Ministry of Health.

Unfortunately, curbing the nation’s exceptionally high rate of maternal deaths has proved far less tractable.

Although exact figures are difficult to come by, officials estimate that every year 20,000 women in Indonesia die from birth-related problems. That figure — representing about 390 women for every 100,000 live births — is a 15 percent improvement over the past decade. Still, “it’s 50 times higher than in developed countries, and three to six times higher relative to other ASEAN countries” such as Malaysia, Thailand and the Philippines, Dr. Rachmi Ontoro, head of the Indonesian Health Ministry’s Directorate of Family Health, said last week.

As part of a global initiative in the 1980s, Indonesia adopted a goal of reducing maternal deaths 50 percent by the year 2000 — from 450 per 100,000 live births in 1986 to 225. But despite considerable attention to the problem, including support from top government officials, the country is unlikely to achieve that goal, Rachmi acknowledged. She added: “We do hope we can get there by the end of 1999,” which is the end of the Sixth Five-Year Development Plan (Repelita VI).

New mothers in the maternity hospital (rumah bersalin) of a community health center in Tebet, South Jakarta, prepare to feed their day-old infants. (Photo by D.L. Parsell)

On April 7, in observance of its “World Health Day,” the World Health Organization (WHO) chose “safe motherhood” as the theme to draw world attention to the problem of maternal mortality and urge greater commitment to combating it.

Dr. Robert Kim-Farley, the WHO representative to Indonesia, explained during an interview in his office that reducing maternal mortality has been far tougher than for infant mortality because interventions required to improve the situation are complicated and expensive. “It’s a more complex problem, with more complex solutions,” he said.

Major progress in curbing infant mortality in developing countries, he pointed out, has come largely from widespread adoption of fairly simple but proven remedies such as immunizations and oral rehydration (to counter diarrhea). Reducing maternal mortality, however, “takes a sophisticated system in place to be effective,” he said.

Among the requirements that he and other health experts cite are more and better trained medical personnel, an adequate network of well-equipped health facilities, a strong referral system for emergency and specialized treatment, and close monitoring of high-risk pregnancies. Other critical needs are greater awareness of pregnancy- and birth-related risks, and community support to provide pregnant women, especially poor and rural women, with better access to heath care services. At the same time, countering deeply ingrained beliefs and values – such as a fatalistic attitude of pasrah (resignation), or acceptance that maternal death is God’s will — is a hurdle. “It takes a generation to change ways of thinking,” Rachmi said.

“We know what we need to do, but how to apply it effectively on a massive scale, with limited resources, is a challenge,” Kim-Farley said. “Fortunately, the magnitude of the problem and the difficulties of intervention are being recognized by the government, donor agencies and NGOs (non-governmental organizations).”

One project aimed at speeding up progress was launched by President Soeharto in December 1996. On National Mother’s Day, he announced a collective initiative called the “Mother Friendly Movement” (Gerakan Sayang Ibu). Coordinated by the State Ministry for the Role of Women, it calls for more than half a dozen ministries to collaborate with grassroots groups to improve the quality of life for women and accelerate the reduction of maternal deaths.

Troubling statistics

The biggest cause of maternal deaths in Indonesia, according to health officials, is excessive bleeding. Rachmi estimates that it’s to blame for 40 to 60 percent of all cases, followed by sepsis and infections (20 to 30 percent) and hypertensive disorders such as eclampsia (20 to 30 percent).

In other countries, it’s generally thought that as many as one-fourth of all maternal deaths are related to infections stemming from unsafe abortions. Because abortion is forbidden in Indonesia, there is no reliable data, but some health experts say privately that such cases here help account for the high number of deaths from infection.

According to Dr. Kokila Vaidya, a WHO medical officer for maternal and child health who is working with the Indonesian Ministry of Health, about 15 percent of all pregnant women in Indonesia are at high risk for complications, and 5 percent need emergency operations.

While women in Jakarta and other major cities tend to give birth at hospitals and clinics, at-home births still make up 70 percent of all deliveries in Indonesia. (Photo by D.L. Parsell)

Obstruction of labor – such as when the baby’s head is too large – requires delivery by Caesarean section, which can be done only by trained professionals. Hemorrhaging caused by a ruptured uterus or other complications necessitates a prompt blood transfusion for the mother; without it, she can die within two hours from acute loss of blood. Thus, it’s critical that an adequate supply of safe blood and transfusion equipment be on hand, which can be a problem in some areas.

Poor nutrition also plays a role. Iron deficiency anemia, for example, increases the risk of spontaneous abortion and of death during hemorrhaging. According to statistics from Indonesian officials, based on household surveys in recent years, as many as half of all pregnant women in Indonesia suffer from anemia

A major reason why women in Indonesia and other developing countries die from the effects of childbirth is delays and barriers to adequate care. One thrust of the “Mother Friendly Movement” is a program — dubbed 3 T’s (for terlambat, or “too late”) — to spread the message that “delays can kill”:

  • delay in deciding to seek care;
  • delay in arriving at a health care facility; and
  • delay in receiving adequate care upon arrival.

An array of different factors contributes to each phase of these delays, such as lack of transportation, community isolation, ignorance about danger signs in pregnancy and delivery, low economic and educational status, and religious and cultural attitudes.

Because these factors are varied and complex, Rachmi said, solutions to maternal mortality must entail a “multi-sectoral approach”—one aimed at improving education and reducing poverty among women as well as increasing their access to health information and services. “It’s a cultural and social problem as well as a health problem,” she said. “Health care deals with only the immediate impact, while not addressing the underlying problems, which are related to the low status of women in society.”

Broad-based efforts

Indonesia has struggled for decades to find effective ways of reducing maternal mortality. For the most part, programs to address the problem have been wrapped into broader efforts to strengthen family health services overall.

Beginning in the 1960s, the government focused on building a network of community health centers, or puskesmas (from pusat kesehatan masyarakat), to provide primary care referrals in every sub-district. A shortage of medical personnel, however, made it impossible to meet the goal of having a midwife and a doctor at every one.

To help counter the shortcomings, the government called for greater community involvement, especially to curb high infant and maternal mortality. One outcome was the creation of a system of local posyandu (for pos pelayanan terpadu), integrated health service posts for mother and child care, nutrition and family planning. These were operated by midwife-trained volunteer social workers (kader) from the community, who came to form the influential government-sanctioned group known as the PKK (Pendidikan Kesejahteraan Keluarga), or Family Welfare Movement.

By the end of the Fifth Five-Year Development Plan that ended in 1994, there were more than 6,000 puskesmas throughout the country, each staffed with at least one physician and one midwife. During the same period, the government launched a program to train a corps of midwives (bidan di desa) who could offer more highly skilled assistance in deliveries than that of traditional birth attendants (dukun). In the past four years, health officials say, some 54,000 midwives have been trained and deployed to villages in every province.

Tebet Puskesmas in South Jakarta is an impressive example of how an adequately staffed and equipped community health center can help make inroads into reducing maternal and child mortality. The center – with more than three dozen medical professionals and midwives — has 20 basic health programs, an array of specialty clinics, strong community outreach and a maternity hospital (rumah bersalin) of 14 beds. In conjunction with two hospitals, eight affiliated village health centers and 123 posyanduTebet Puskesmas serves a subdistrict of 66,000 households.

One day recently, the bright and well-scrubbed clinic was bustling with activity in the maternity ward, where a group of new mothers welcomed their bundled day-old infants. Dr. Zulhaini Hadi, director of the clinic, said about 100 babies are born each month at the clinic. “Last year,” she noted proudly, “we had no maternal deaths.” An obstetrician/gynecologist is always on call for complicated cases, and women who are referred to a larger hospital because of problems during delivery can be transported by ambulance.

“In Jakarta, most women want to go to the doctor to deliver their babies because they think it’s safer,” explained Dr. Augustinus, a staff dentist at Tebet Puskesmas who led visitors on a tour of the facilities last week.

Adapting traditions

But the sobering reality is that 70 percent of women in Indonesia live in the countryside and still give birth at home. This is largely the result of poverty and lack of ready access to a health care facility, but health officials say tradition and beliefs contribute strongly. “Because of religious inhibitions, they often feel more comfortable at home,” Vaidya noted. “They also have more confidence in traditional birth attendants than in young trained midwives.”

But health experts say village-based dukun generally know little about possible complications during deliveries. “Without proper training, they may not recognize the danger signs until it’s too late to transfer the woman to a health care facility,” Kim-Farley pointed out.

In some cases, the traditional practices of dukun may even be harmful. As an example, Vaidya explained that when a birth assistant massages a woman’s belly during labor before the cervix is fully dilated, it can rupture the uterus. Too, dukun may not realize the importance of thoroughly removing all pieces of the placenta, which otherwise can lead to fatal hemorrhaging. Another serious problem of at-home births that health officials cite is unhygienic conditions, which can cause deadly infections.

Because dukun remain popular, however, the government is searching for ways to redefine their roles while trained midwives assume the responsibility of performing deliveries. “In reality, dukun do more than assisting at birth,” said Kim-Farley. “They also provide cooking, cleaning, bathing of the mother and other supportive services that families appreciate. We need to get (trained midwives and traditional birth attendants) working as a team. It doesn’t have to be one or the other.”

A newly published report by the State Ministry for the Role of Women and the Ford Foundation, The Mother Friendly Movement in Indonesia, describes efforts being carried out in eight trial districts -– which together account for 70 percent of all maternal deaths in Indonesia — to overcome barriers to safe motherhood. The community-based initiatives include efforts such as these:

  • PKK volunteers (kader) have assumed the responsibility of identifying and monitoring all pregnant women in their districts. They record medical data on standardized cards, and post tags or other markers on each house where a pregnant woman lives, with a special designation that identifies women at high-risk. These volunteers also disseminate information about the importance of proper nutrition, and promote awareness of possible risks in pregnancy and childbirth.
  • A variety of efforts is being made to improve the technical skills of village-based midwives. Training programs conducted at hospitals or by visiting physicians are designed to make midwives more competent in dealing with high-risk pregnancies and deliveries as well as routine births. Puskesmas doctors also getting more specialized training in emergency obstetric care.
  • Districts have devised a number of innovative ways to meet the transportation needs of high-risk pregnant women who are referred to puskesmas or hospitals. “Village ambulance cooperatives” have been organized, and one district established “Mother Friendly Waiting Homes” as places of temporary transit to reduce the travel distances for women who live in isolated villages.
  • To address poverty and alleviate concerns among pregnant women and their families about the costs of hospital deliveries, special Safe Motherhood funds have been established with government “seed money” and community donations. Couples also are counseled about the importance of setting aside money for birth-related costs.

The religious community in Indonesia has taken an active role in the “Mother Friendly Movement,” with Moslem leaders incorporating themes of family welfare and safe motherhood into their sermons. By way of explaining such strong support, Rachmi said the teachings of Muhammad include stories that counsel people to show respect toward their mothers.

“Community mobilization around the issue of safe motherhood,” Rachmi added, “has been remarkable.”

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