Chances of surviving childbirth improving in Bali

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.