Maternal deaths continue despite all the pledges

Meiwita Budiharsana, Program Officer, Ford Foundation, Jakarta Office

In two years, Indonesia must report the results of a decade of the implementation of an action program agreed upon at the 1994 Conference on Population and Development in Cairo. Do the current health programs reflect the government's seriousness in realizing its international commitment? Has the fairly large Indonesian delegation that attended that conference consistently implemented the declaration that they signed?

The fact is, there have been many programs here -- but no real changes.

The basic system for monitoring and reporting births, marriages and mortality rates in Indonesia has yet to produce comprehensive vital registration data. Without well processed data or accurate estimates for the annual program planning, the policies drafted from one year to the next are based on "guesstimates" alone.

Since the 1994 Household Survey (SKRT), which came up with an estimated maternal mortality rate (AKI) of about 340 per 100,000 live births, a decline has never been reported. Yet it has repeatedly been stated at every seminar and workshop that compared to other Southeast Asian countries, Indonesia has the worst AKI.

Unfortunately, statistics alone are not sufficient in bringing about significant changes. There is no sense of urgency to allocate an adequate health budget (at least 5 percent to 10 percent of a total regional budget), so that 15 percent of this amount can be concentrated on programs to lower maternal and neonatal mortality rates (in the latter case a newborn is expected to survive the first 28 days).

It is not surprising that the situation in the central government is replicated in the regions. As we embarking on the era of decentralization with missing accurate data, predictably, the hope of obtaining a commitment from regional legislative councils and regents to allocate adequate funds to lower the maternal mortality rate is grim.

"A high maternal mortality rate" remains an expression that fails to move anybody reading or hearing it. It also has failed to introduce changes such as integrating the "usual" vertical health planning and programming.

Who should be responsible to change this situation? Is it supposed to be a shared responsibility? Whose responsibility is it to guarantee that the basic human rights to life and equitable access to quality health care is fulfilled?

Sharing of responsibility among ministries, complete with systematic monitoring and evaluation of costly programs, is needed. This is the greatest challenge to the Office of the State Minister for Women's Empowerment and women's non-governmental organizations (NGOs).

A genuine partnership between both parties is fundamental to take control of maternal and neonatal deaths.

A genuine partnership means listening with great concern and attention to NGOs who recognize the right of women to access equitable information and comprehensive reproductive health services -- not fragmented as in the current health system.

The current health system consists of vertical programs that separate the planning and budgeting processes of the four essential components of reproductive health care for over 30 years. Maternal and child health has been delivered separately from family planning, and does not pay attention to barriers to access to proper detection and treatment of sexually transmitted infection. Not to mention that adolescent services merely focus on primary school-age children, leaving out the out- of-school youth who comprise almost half of the adolescents above 15 years old in this country.

In the near future we will see the impact of decentralization, in which the allocated health budget will shrink at the district and lower levels. There is no longer such a thing as absolute top-down directives from Jakarta. With no convincing advocacy to the district and subdistrict heads and local legislative councils, almost certainly the use of the annual development budget will concentrate around the construction of physical facilities -- instead of human resources development focusing on reducing the risk of maternal and neonatal deaths.

The Office of the State Minister for Women's Empowerment must take firmer action in convincing relevant ministries that a faster reduction in the maternal mortality rate requires not only public participation but, more importantly, also changes in program strategy.

A "shared responsibility" campaign will not be effective unless there is unity in planning and implementing a program strategy. Shared responsibility can be demanded only when the women's rights to participate in planning, priorities setting, monitoring and evaluation are guaranteed.

NGOs have written a lot about women's need and rights to obtain information and effective reproductive health services. A book published last year titled Sketsa Kesehatan Reproduksi Perempuan Desa (Sketches of the Reproductive Health of Rural Women) was written NGO staff who daily assist rural women farmers. The book reflects years of work which established a bonding trust among women farmers that is conducive to the sharing of feelings and experiences, including sexual and reproductive experiences.

This book, edited by Sri Hadipranoto and Heru Santoso, compiles true stories reflecting the factors contributing to the high maternal and neonatal mortality rates. The book includes stories of sexual harassment, the fear of unwanted pregnancy due to expensive and scarce contraceptives, the experience of going through unsafe abortions, the enduring of stigmatized infertility owing to sexually transmitted diseases, and poor participation and empathy of husbands of women who face the risk of death carried by unsafe abortions.

Strategic changes must be targeted at a series of direct and indirect causes of maternal mortality voiced by people at the grassroots level. In line with the general principles of preventive health, early diagnosis and proper treatment are only promising when the causalities are known.

The success measures of a "shared responsibility" campaign depends on whether we can include the voice of the grassroots NGOS in the planning and changing strategies, for a program aiming to speed up the decline in maternal death risks.

The above is based on a presentation the writer gave at a seminar on maternal mortality on March 12 in Jakarta.