Maternal deaths continue despite all the pledges

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.