Midwives must be `a little smarter than doctors'

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."