High maternal death rate receives poor attention

By Rita A. Widiadana

JAKARTA (JP): As her ignorant and irresponsible husband looks on, young villager Siti Zubaedah dies a painful death from hemorrhaging during childbirth.

It is a scene from a TV drama, Perkawinan Siti Zubaedah (The Marriage of Siti Zubaedah), but it remains the terrible reality for millions of Indonesian women.

They endure severe complications during pregnancy and childbirth due to undesirable physical, mental and social factors. Many lose their struggle.

Many maternal deaths in the country, especially in poor and remote areas, are unreported and unrecorded, said Kumara Rai, director general of community health of the Ministry of Health, in a recent meeting here.

"It is like a jumbo jet full of women crashing every week, but nobody hears of it, no one makes a fuss," said Kumara.

Perkawinan Siti Zubaedah, screened last year, directed by Teguh Karya and jointly produced by the National Family Planning Board, the private TV station TPI and John Hopkins University, is a cinematic means of educating the public about the problem.

Every year, more than 20,000 women in Indonesia die during pregnancy and childbirth. The average national maternal mortality rate (MMR) is 400 per 100,000 live births, by far the highest among Association of Southeast Asian Nations (ASEAN). By comparison, Singapore has 10 per 100,000 live births, Malaysia 40 and even Vietnam, one of the region's poorest nations, has 110.

The figure for Indonesia, estimated by the World Health Organization (WHO) and the Ministry of Health, is even higher in the eastern provinces. In Irian Jaya, the rate is estimated to be between 575 to 874 per 100,000 live births.

Most of them die of hemorrhaging or other complications, and unsafe and unhygienic childbirth delivery due to lack of access to professional medical assistance.

About 99 percent of all maternal deaths in the world occur in developing countries, and 40 percent are accounted for by Southeast Asia, including Indonesia.

WHO identified lack of basic medical facilities, nutritional deficiencies and social conditions as contributing factors.

Suffers

More than 50 percent of women in developing countries suffer from iron, vitamin and protein deficiencies which lead to serious anemia. These predisposing conditions will also increase the risks of other complications like eclampsia, high blood pressure and goiter, further endangering the development of the fetus and the newborn.

In Indonesia, 51.3 percent of pregnant women and lactating mothers suffer from acute anemia due to poor nutrition.

Proper nutrition is not merely dependent on the availability of food but also good sanitation and, more importantly, a caring environment. This is often grossly deficient, especially in the case of young women.

More than 65 percent of Indonesian women live in villages where basic medical facilities are still a luxury and social discrimination against women persists.

In Indonesian and other Asian countries, female children and young women, particularly those living in rural areas, are commonly discriminated against in all matters, including the best portions at meals. When these girls grow up, they are often physically weak and unhealthy adults.

The nutritional deficiencies are often combined with a disproportionate share of the workload. In the region's villages, it is women who must wake up before dawn and walk several kilometers to fetch water for their families. Young girls must stay at home while their brothers go to school because their parents are too poor to educate everyone. Most girls are married off young when their reproductive organs are not yet developed fully.

This is of little concern for their parents, who are keen to see them marry young because that relieves them of the responsibilities of looking after them.

For the girls, an early pregnancy means not just the end of their childhood, but it also exposes them to serious risks. According to a United Nations survey, girls aged 15 to 19 were twice as likely to die of prenatal and postnatal problems compared to women aged over 20.

Despite the alarming number of maternal deaths, many people still regard these tragic fatalities as natural and ordinary occurrences for a woman during motherhood.

Not everybody agrees: Robert J. Kim Farley, WHO's representative for Indonesia, is among them.

"Pregnancies and childbirth are not only women's problems and responsibilities. They are ours. All members of the society have a daunting task to help ease these women's burden."

Problems relating to pregnancies have garnered global attention, he added.

WHO dedicated this years's World Health Day, which fell on April 7, to medical care for mothers with a target to cut the maternal fatality rate by half in 2000. The current world average MMR is 430 per 100,000 live births.

Priority

The Indonesian government has made a positive response by running several health programs to provide basic medical facilities and a desirable social environment for women.

Minister of Health Farid Anfasa Moeloek has committed as his first priority the attainment of the WHO target in 2000.

"It is high time for us to pay very serious attention to the improvement of health conditions of Indonesian women in general, and children and women of reproductive years in particular," he said.

The government, supported by international agencies like WHO, the United Nation Children's Fund (Unicef), World Bank, Asian Development Bank (ADB) and various non-governmental organizations, has been running intensive programs called Gerakan Sayang Ibu (Mother Friendly Movement) and Safe Motherhood since the early 1990s in addition to its National Family Planning.

The programs have been implemented in the country's 27 provinces although their effectiveness has yet to be studied due to the current social, economic and political crisis.

Stephen J. Woodhouse, Unicef's area representative for Indonesia and Malaysia, previously said that Unicef and other international donor agencies would be willing to support safe- motherhood programs in the country.

"Providing basic medical facilities will not only save these mothers's lives but also those of at least 1.5 million babies every year," Woodhouse noted.

Unicef, he said, had made reductions in maternal mortality its highest priority. Health is part of women's empowerment, along with education, employment and social reform.

"Women's health is more than just reproductive health. It involves a wide range of issues covering the entire life span of women's lives," Woodhouse said.