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Last Updated: Saturday, 22 May, 2004, 23:39 GMT 00:39 UK
Indonesia's maternity care under fire
By Kate McGeown
BBC News Online

Indonesian women
Many women still give birth with the help of untrained midwives
Indonesia has the highest maternal death rate in South-East Asia.

More than 300 out of every 100,000 pregnancies end in the woman's death - far higher than other countries in the region, and six times higher than in neighbouring Malaysia.

The Indonesian Government is trying hard to reduce this statistic, with a series of new policies designed to improve prenatal care. But so far they have had limited success.

The statistics speak for themselves - an Indonesian woman dies every hour from complications during delivery, late referral to hospital or poor emergency care, according to United Nations figures.

Dr Laura Guarenti, a World Health Organization representative in Jakarta, says there are many different reasons for Indonesia's abnormally high level of maternal mortality.

One of the main stumbling blocks is the country's geography.

"Indonesia has 17,000 islands, and this presents a real problem," Dr Guarenti told BBC News Online.

"If a woman has a severe haemorrhage, you need to refer her to hospital within two hours, and it's very difficult to do that in some areas."

Mustika, a midwife, agreed. She said she often saw cases where women simply arrived too late to be saved.

"I saw it a lot. These women had just lost too much blood; they were very pale and weak," she said.

She added that midwives in remote villages often had to go to the homes of women in labour to give blood infusions, because they were not be able to get to a hospital or clinic in time.

Another major cause of maternal death in Indonesia is the high incidence of unsafe abortions.

According to a study by the Indonesian Society of Obstetrics and Gynaecology, half of all abortions in Indonesia are performed in unsafe conditions.

Abortions are technically illegal, but an estimated 2m are still carried out every year.

"There are many abortion cases everywhere," said Masruchah, a spokeswoman from the Indonesian Women's Coalition.

"Often it's because of the stigma. If you are pregnant and not married, you don't have a place among the people," she said.

Sri Hermiyanti, the head of the government's family health directorate, admitted that abortion was a "sensitive problem" in Indonesia.

She said the government was campaigning for an increase in the use of contraceptives to bring down the number of cases.

Traditional practices

According to the government, access to qualified health personnel is a key factor in improving maternal mortality rates.

Dr Guarenti estimates that one third of Indonesian women have no skilled attendant present when they give birth.

This is partly because of a lack of staff, but also because of cultural and social factors.

"Indonesia has over 300 ethnic groups, and in some cultures it is seen as better for women to deliver at home with the help of a traditional birth attendant than in a hospital or clinic," said Sri Hermiyanti.

These things cannot change overnight
Dr Laura Guarenti, WHO
Masruchah, from the Women's Coalition, added: "Right now a lot of people use the help of untrained midwives to deliver their babies, and the number of deaths from cases like this is high."

The government has launched a policy to partner these unskilled traditional helpers with qualified midwives, to encourage pregnant women to use modern medical services.

But even if the women are convinced of the benefits, it is sometimes difficult to persuade their families, especially in more traditional rural areas.

Mustika said that some of her colleagues in Kalimantan have had to ask village leaders to approach families and explain the importance of medical help.

There is no doubt Indonesia is trying to take steps to improve its levels of maternal care.

Last year the mortality rate reduced slightly -from 373 per 100,000 women in 2002, to 307 per 100,000 women in 2003.

But Indonesia is still lagging behind the rest of South East Asia. Even poorer countries such as the Philippines achieve much better results.

"These things cannot change overnight," Dr Guarenti conceded. "The priority now is training staff, and that takes time."

Meanwhile the midwives struggle on. "We do what we can," said Mustika, "but it's hard."

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