Despite progress in reducing maternal deaths in Indonesia, international organizations, health professionals and community workers say pregnancy still puts the health of women at greater risk.
The national maternal mortality ratio (MMR) has gradually come down from 390 deaths per 100,000 births in 1991 to 228 in 2007, according to the Health Ministry. The independent Countdown to 2015 report, released in 2012, puts the current MMR at 220 deaths per 100,000 births.
But this figure does not apply to all parts of the archipelago, which includes some 17,000 islands. “Eastern Indonesia faces severe problems in terms of access to remote areas,” said Bill Hawley, Indonesia country director of the US government Centres for Disease Control and Prevention (CDC).
“It has a myriad islands and difficult highland terrain in Papua [Province], with the quality of healthcare also varying due to differing levels of commitment in each district. The ratio is perhaps two to three times higher in eastern Indonesia… [which] has a weaker health system and a higher burden of infectious diseases, including malaria,” Hawley said.
Pregnancy weakens women’s immunity, making them more susceptible to infection and increasing the risk of illness, severe anaemia and death. Maternal malaria increases the risk of spontaneous abortion, stillbirth, premature delivery and low birth weight.
Some 45 percent of maternal deaths nationwide are caused by malaria, heart failure, hypertension or respiratory problems, according to the Indonesian Health Ministry, while another 50 percent are caused by heavy bleeding during pregnancy or labour and seizures (eclampsia).
“Dying” community clinics
Despite nationwide free maternity care at community health centres, more women are dying in childbirth. Provincial health reports note that there were 4,498 maternal deaths in 2009, 4,662 in 2010, and 5,118 in 2011, numbers that reflect a growing population.
“In rural areas, 70 percent of births still take place at home, where access to the necessary facilities to handle complications does not exist,” said Edward Cawardine, a UN Children’s Fund (UNICEF) spokesman in Indonesia. “Only a third of Indonesian women, on average, receive the recommended intake of iron supplements critical to reducing the risk of anaemia, which in turn impacts on maternal mortality risks.”
Government data in 2007 showed there were fewer than 23 health workers per 10,000 residents, the internationally accepted minimum number needed to provide basic lifesaving care.
Services at community-based clinics, known as posyandu, are declining. “Posyandu provide an early warning detection mechanism for problems relating to pregnancy,” said Yusma Sari, a coordinator at the Kartika Sukarno Foundation (KSF), a local NGO that supports community clinics on the islands of Sumatra, Java and Bali.
“They’re really important for identifying malnourishment, along with checking the weight of pregnant women and issuing them with vitamins,” she said. “Posyandu are dying. The government [used to send] midwives to give… medical expertise, but this support has decreased. Also, posyandu used to hold sessions for pregnant women every day, but now it’s once a month.”
Sari said reduced medical support from the government has discouraged people from volunteering to staff the posts, which in turn has discouraged patients from coming. The posyandu are community-organized and run, so government support is not automatic and must be requested.
Lack of understanding among community members about their role running a clinic, poor patient service, and weak knowledge among women of their health needs during pregnancy, have not helped. “Posyandu don’t have any skilled people,” said Ibu Meme, 27, who lives in Jakarta and is eight months pregnant. “There’s certainly no special treatment for pregnant women available there.”
Commonly held misconceptions are another cause for the slow decline in the MMR. “I’ve visited communities where pregnant women are told not to eat vegetables because of perceived negative side effects on the child after birth,” said the KSF’s Sari. “But vegetables are an important source of iron that pregnant women need.”
Sari also said other common traditions, such as men receiving larger food portions than women, mean pregnant women in rural areas and poor urban communities often consume too few nutrients.
The Indonesian Health Ministry has tried to introduce information about reproductive health and balanced diets into the national education curriculum, but low awareness among local government officials and a decentralized health system make it difficult to change attitudes from the seat of government in Jakarta - some 4,000km from the furthest point east in the archipelago.