Chances of surviving childbirth improving in Bali

By Leyla Alyanak

BULELENG, Bali (JP): When 19-year-old Sukry began hemorrhaging during childbirth, the traditional midwife stood by helplessly. The nearest health post was only 15 kilometers away but Sukry had no transportation. She eventually delivered a healthy baby, but lost her life doing it.

That was five years ago.

Today, under a new national campaign, an ambulance would have been waiting to whisk her to the clinic, a trained midwife would have been on standby and any potential complications would have been diagnosed early on.

In Indonesia, too many mothers die while giving birth, a fact officials had not realized until the 1994 census data began rolling in.

The figures made no sense. Everything else was improving -- child mortality was down, as were fertility and population growth rates. Yet mothers continued to die. However hard they tried, health officials were stuck at 450 maternal deaths per 100,000 live births.

"In the decade leading to 1994, there was no sign of reduction in maternal mortality in Indonesia," said Abdullah Cholil, a top official at the office of the State Minister for Women's Roles, which coordinates the campaign. "Worse, we had the highest level of maternal mortality of all ASEAN countries."

Cholil's team looked for answers. "The medical causes were easy to identify -- hemorrhage, infection, toxemia," he said.

"But these would not have occurred without what I call the three delays: delay in recognizing the danger and deciding to seek help, delay in getting to a health post and delay in getting medical attention once you get there."

He set about to eradicate them.

Trials were conducted in eight districts which together account for 70 percent of all maternal deaths in the country, and results were encouraging. Cholil took his figures to President Soeharto and received the green light for a national campaign, Gerakan Sayang Ibu, which roughly translates into "mother- friendly movement". It aims to halve the number of maternal deaths in the country by the year 2000.

The campaign is simple and centers around a volunteer from the Family Welfare Movement (PKK), one of Indonesia's largest women's groups.

Volunteers

In each village, volunteers organize expectant mothers into groups of 10, called desawisma, and shepherd them through pregnancy. The pregnancies are monitored regularly and any sign of trouble is reported immediately. A PKK volunteer is responsible for each group so they can step in if there is trouble, by providing transportation or money, for example.

The volunteer is chosen locally by the 10 women so she knows their problems intimately. She meets once a month with the mothers, and explains the national program to them. Every three months, all the groups in the village meet.

The campaign has been finely crafted because authorities know orders from Jakarta will not necessarily change attitudes in the countryside. It cuts across sectors, since no single ministry can hope to deal with such a broad problem; it is multidisciplinary, covering issues ranging from the role of women to religion to ethnicity; it targets men as well as women, since men are often responsible for delays in getting women to hospitals; it is a local initiative, run by local authorities rather than imposed from above; and it monitors women throughout their pregnancy to make sure they have the care they need.

"We keep family records, and this allows us to track the mother and intervene if there is trouble," said Trikomala Hairsjam, a senior member of the PKK unit which deals with health, environment and the family.

"Sometimes the women do not want to come so we encourage them by providing transport or information. We promote self-reliance on the part of the mothers, which gives them the opportunity to understand what is happening to them, and then to do something about it."

This is no mean feat in a society dominated by tradition. Women facing childbirth complications are often ignored by their husbands, or require their permission before seeking medical help. Their husbands may not consider transport essential and might let them linger until it is too late.

While Indonesia's constitution does not discriminate against women, cultural values often militate against equality. Women may make decisions related to running the home, but tend to defer to their husbands when those decisions affect the outside world, such as when to get treatment for a medical emergency during childbirth.

A few days ago, campaign results began to trickle in from Bali's Buleleng district, the first on the island to come in with figures. Last year, 12 women died from childbirth-related complications -- there has been none this year. Much of this is due to improved monitoring and health care, officials say.

"When I first came here three years ago, about 40 women a year gave birth with traditional birth attendants," said Katut Suwerni, head of the Buleleng posyandu (integrated health post). "This year there were only nine. Mothers now know about the risks of traditional childbirth and they would rather come here, where the equipment is sterile, there is less risk of hemorrhage, and they can now have free transport if they need it."

Some of the reasons behind the results in Bali may also be cultural.

Participation

"We have high participation among women so the results are better than in some other regions," said Ayuputu Nantri, vice- president of the provincial legislature. "But there are still problems. Women suffer from anemia because in this culture, they feed their husbands and children first and only eat the leftovers. And the women also work at hard labor, such as roadbuilding or construction, which makes them more vulnerable."

In Indonesia, about 44 percent of pregnant women are anemic, compared with 29 percent of non-pregnant ones.

The mother-friendly movement requires prodigious coordination among its diverse partners: ministries dealing with women, the interior, health and population, all levels of government and non-governmental organizations. Also involved are multinational agencies such as the United Nations Fund for Population Activities (UNFPA) and the World Health Organization, which are all in some way involved.

Lack of coordination can be fatal, Cholil warned.

"In a remote village of Java," he said, "a mother began to hemorrhage while giving birth. The midwife decided to take her to the district hospital but there was only one available vehicle, an open truck."

At the entrance to town the truck was stopped by a traffic policeman. "Open trucks are not permitted to carry people, he told them," Cholil continued. "As they discussed and negotiated, time passed. When they finally got to the hospital it was too late. The mother was dead. Had the policeman understood the importance of getting the mother to the hospital quickly, he would have let them pass."

At 25, Alfi Chandra is expecting her first child. The Balinese farmer's wife is a little anxious because she remembers what happened to her friend Sukry.

"But I feel safer now," she said. "I know I am not in danger ...but if I have complications, the ambulance will take me to the health post."

For Alfi and thousands of prospective mothers like her across the country, the chances of surviving childbirth are getting better every day.