Midwives must be `a little smarter than doctors'

Text and photo by Tri Hafiningsih

JAKARTA (JP): Most of the time, Tiara Sianturi is just an ordinary bidan (midwife) who works in a small maternity clinic in a remote part of the Malaka Baru district, East Jakarta. But there are times she claims she must be "a little smarter" than the doctors.

She said many of her patients come from low-income families with poor health knowledge. "These mothers-to-be come to me when they are already in critical condition, so there is little I can do," she said.

Sending them to hospitals, she said, is sometimes out of the question. "They are so afraid of hospitals that they want only me to help them in labor," she explained slowly in her thick Tapanuli accent.

Poor services are another reason the poor people avoid hospitals. "They tell me that every time they go to a hospital, the ward attendants end up yelling at them for their poor knowledge of health care or hospital admittance procedures," she said, adding that the problem is not uncommon among such people, as many of them are illiterate or elementary school dropouts.

According to the former nurse, hospitals and their doctors often lack the patience to give necessary explanations to the uneducated. "The patients complain they don't understand why the doctors give them so many injections or medicines, while the doctors complain the patients are stubborn."

The middle-aged midwife recalled a patient who came to her in critical condition.

"She was already `drained' because her ketuban (fetal membrane) had been broken for several hours. She was almost unconscious from loss of blood, and she was emotionally unstable. She decided to come to me after waiting for several hours without treatment at a hospital," Tiara said.

She could not consult a doctor. The baby could have died in the mother's womb, while the mother, who was frightened and in shock, simply refused to be sent back to the hospital.

So the midwife decided to help the mother deliver her baby and send her to another hospital after the baby was born safely. "She was much calmer then, knowing that her baby was okay, and that she would have adequate treatment at the hospital," she said.

Tiara said she never worries her patients will sue her if something happens, although she is concerned because she has limited medical equipment and authority for emergency handling.

"Through experience, I have learned that I should trust my own judgment. I trust the patients as much as they trust me. And I trust that God will always helps me," said Tiara, who started her midwifery career at the Herna hospital, and got her diploma in midwife service in 1985 after serving as a nurse for over 10 years.

During her five-month period at the newly opened clinic in East Jakarta, she has assisted more than 20 deliveries. Many of the patients do not have medical backgrounds and have not had prenatal checkups.

"They usually come to me when they are already in labor," she said.

"I helped a mother deliver twins, one of whom had already died after many hours in the mother's womb. Once I had to do a brain- suction on a dead fetus, still in the mother's womb, and put the brain back in after the baby was born. I also helped a mother deliver a baby, legs first, a critical situation," she said recalling some of her experiences.

She said she had earlier advised the mother of the twins to have an X-ray. "I suspected twins the first time I met her in a checkup during her seventh month of pregnancy. But the mother refused and insisted she was only carrying one baby."

Limits

Another midwife said that midwives have limited authority to give medical treatment in emergency cases.

"We may perform the necessary procedures, but the decision shouldn't be ours, it is the doctor's," said Rita Pasaribu, who received her diploma from the Budi Kemuliaan School -- known as the oldest school of midwife services -- in 1992.

Rita said close supervision from an obstetrician or other specialists authorized to do give medical treatment is always required. "Most of the time, the best action in an emergency is to give the patient the required first aid before sending her to a better equipped hospital," she said, adding that it isn't difficult as the city has many hospitals.

According to the young midwife who spent her first year of midwifery in the Budi Kemuliaan maternity hospital, she sends a patient to another hospital if she refuses to be treated at a particular one. "If she doesn't want to go to the RSCM (Cipto Mangunkusumo General Hospital), for instance, I can send her to Persahabatan, or any other hospital she prefers."

"A normal delivery has its critical moments, let alone the abnormal ones," she said, adding for the sake of the patients and herself that she prefers avoiding unauthorized procedures.

Rita said she could ruin her career if she violated ethics. She is concerned about the risk of losing a patient or a baby in her care. "If my patient or the baby dies, I may be blamed, although it's not my fault. My other patients may not trust me anymore. So to play it safe. I usually advise the patient and her family to seek better services at a bigger hospital in an emergency," she said.

Rita, who is five-month's pregnant, works at the Mariah maternity clinic in the state-owned Perumnas housing area in Klender, East Jakarta. She works in shift with four other midwives. The clinic, open 24 hours a day, also provides the services of an obstetrician, a pediatrician and a general practitioner. The clinic offers full services once or twice a week in the afternoon.

She said most patients at Mariah come from the local neighborhood, and most checkups are done by the midwife in charge. A patient is usually charged Rp 5,000 for a checkup.

Medicines are also available at the clinic. "We usually charge the patients between Rp 6,500 and Rp 9,500, including medicines," Rita said.

The specialists charge the patients much more. "They must pay a minimum of Rp 20,000, excluding medicines," she said.

A patient with a normal delivery is charged between Rp 150,000 (third class) and Rp 250,000. "We have a first class room for Rp 350,000, but no one has ever used it," said Rita.

In-patient services

Midwife Tiara works mostly alone at Mitra Anda clinic, which is also open 24 hours a day. The small clinic, like Mariah in Klender, also provides other services such as family planning consultations and contraceptives, pregnancy and post-natal checkups, immunizations and circumcisions.

The clinic charges similar fees for in-patient treatment as those in Mariah, but includes an economy class fee of Rp 65,000.

An obstetrician is available on call, Tiara said while treating a two-year-old child who had second-degree burns on her right hand.

She told the child's mother to be more careful in taking care of the baby. "You look very tired. I think you should take a little rest from the daily chores and play with the baby for a while. You could have prevented her from touching the hot iron if you had been more alert," she said while applying ointment on the wailing child.

She ground some tablets into powder, separating them into nine equal parts and wrapping each neatly in paper. Slowly, repeating some important information, she told the mother to make the child drink the medicine three times a day before meals and apply the ointment until the burn wounds had healed. She added a small bottle of syrup for the baby's fever.

The patient's mother was asked to pay Rp 5,000 for the treatment and medicines, which she promised to pay "tomorrow."