Health workers face difficulties

By Stevie Emilia

BELU, East Nusa Tenggara (JP): Yeswelda Mali, a midwife in Lamaknen district, wakes up at the first cockcrow, bicycles to the Weluli village clinic, and often waits hours before a pregnant woman finally comes in for an examination.

So great is the distrust of many local people toward health workers, and so great is their reliance on traditional untrained dukun (midwives or healers), that Yeswelda realized early on in her career that if the women wouldn't come to her, then she would go to them.

Like many other trained midwives and health workers, Yeswelda has to cover dozens of kilometers on her bicycle every day, riding through thick forests and over steep hills to ensure women's pregnancies remain healthy.

"The majority of pregnant women are so reluctant to have themselves examined," Yeswelda said.

The maternal mortality rate in Belu, which is 296 kilometers from the province's capital Kupang, is 670 per 100,000 births, while the provincial rate in 1995 is 911 per 100,000 births. Fourteen of every 34 women who died while giving births to their babies in Belu were attended by untrained dukun.

Although the regency rate is lower than the provincial rate, some districts in Belu actually have much higher rates. Weluli district recorded a maternal mortality rate of 1,370 per 100,000 births last year while Biudukfoho recorded 7,070 per 100,000 births.

The head of Weluli clinic, Nurse Veronica S., said that last year in Lamaknen village 364 women died in labor. Five of them died while giving birth in the fields, accompanied only by their husbands or close relatives, she said.

"Even if the women, who had gone to work up to the last minute, wanted our help, it would have been too late because their fields are so remote and difficult to reach," she said.

No doctors have been posted to the clinic since April last year, she said.

"Even if there are complications in the delivery, such as a breech birth, the woman's relatives will first argue among themselves whether to ask for the help of a dukun or a trained midwife," she added. "By the time the arguing is finished, the woman would probably be beyond help."

Head of the Belu's health office Paulus M. Wignyohadi said that 91.3 percent of women give birth in their own homes rather than at community health centers or hospitals, and 52 percent of them are attended by untrained dukun.

"Pregnancy and delivery are considered a natural occurrence here, and most people trust the traditional midwives more then trained health workers," Paulus said. "Besides, the dukun are cheaper."

Adirambu, a pregnant patient at Veronica's clinic, said that although she has been examined at the clinic, she would ask a traditional midwife to help her deliver her baby.

The health authorities have tried to solve the situation by training traditional midwives. The program started in 1987 and it was trained midwives such as Yeswelda who had to travel long distances to seek the dukun and train them.

There are currently 532 dukun who have been trained and 537 untrained dukun in the regency.

Attitude

Experts have acknowledged that one of the most difficult tasks health workers face in their efforts to reduce the province's maternal mortality rate, which is twice the national rate, is changing the attitude of the local people.

"Their belief in untrained dukun and their distrust toward professional health workers are something that cannot be changed overnight," said E.H. Pelokilla, the governor's assistant for community welfare. "There's no magic. We realize we have to work hard over a long period of time."

"A total of 58 percent of women in labor turn to dukun instead of doctors or skilled midwives," she said. "Only 15 percent of them go to midwives and three percent to doctors, while the rest ask for their families' help."

She pointed out that poor education is the main reason for the ignorance. "Most women here won't go to the doctor unless they have severe complaints."

Women are also reluctant because they think that if they seek health workers' help too often, they'll be mocked because it would mean they had too active a sex life, according to Susi M. Dauselt Katipana, an officer of the United Nations Children's Fund (Unicef).

Another problem that health workers have to contend with is changing the dukun's ways of assisting women in labor. "We can't just make them abandon their traditional ways. What we need to do is help them see the importance of preparing a hygienic delivery," Pelokilla said.

The province has a population of 3,473,000 spread through 1,626 villages in 42 of its 566 islands.

Pelokilla said anemia is another reason for the high mortality rate in the province. A total of 51 percent of women who died during labor were anemic, she said.

There's a belief among the people that pregnant women should not eat eggs, fruit, fresh or fried fish. All of these are in fact very important for their health, she said.

In addition, there's the classic problem of having insufficient medical personnel and inadequate equipment, Pelokilla said. "There's not much we can do about this. For instance, there's only one gynecologist serving the whole province," she said.

There are only two doctors, 13 trained midwives and 41 junior midwives in 13 community health centers serving the 228,000 people in the eight districts in the Belu regency.

Limited funds is to blame for the province's failure in recruiting more doctors, she pointed out. "Doctors work here only because they have the post-education three-year contract with the government. After that, they'll be gone," she said.

In 1995 the average per capita income was Rp 550,000 (US$234), one of the lowest figures in the country.

The provincial government, in cooperation with Unicef, has been making great efforts to lower the maternal mortality rate here. Regretfully, not many people understand that hard work is involved before the endeavor can succeed, according to Esthon W.L. Foenay of the provincial administration.

The head of the bureau in charge of setting up programs on women and children's health said that local people, including officials, often see funds from donors such as Unicef only as extra money to be spent.

In 1993/94, the local government allocated Rp 256 million for the women and children's health programs, while Unicef assisted with Rp 2.4 billion. In 1994/95, there was Rp 416 million allocated by the government, along with Rp 3.9 billion from Unicef.

"The community should realize that the fund is there to help women and children improve their health," Esthon said.