For years, more children died in the remote village of Ciroyom than in any of the other villages in the area. PNPM Generasi has successfully reduced its infant mortality rate.
Nearly 150,000 children under the age of five die every year in Indonesia, most of them during birth or in the month following birth. Most of these deaths are caused by premature birth and severe infections such as pneumonia, meningitis, and septicemia. Another reason is the lack of medically trained midwives attending the birth process.
To reduce the infant mortality rate, the Indonesian government has introduced a number of programs in recent decades to make sure that qualified midwives are available to attend births, and that pregnant mothers use the services of the midwives. The programs are also to ensure all children are given vaccinated against deadly infectious diseases. Children are given vitamin A and other supplements and their weights are checked regularly, so if any of them are underweight action can be taken immediately. The programs have created a very positive impact. The infant mortality rate has plunged by about half since 1990s .
However, there are still many Indonesian women giving birth without being properly attended. They usually live far away from where the midwives work, often because health agencies can’t find midwives willing to be posted in remote areas.
Even when there’s a midwife, pregnant mothers often prefer to use traditional birth attendants because they are familiar members of the community and because they are cheaper. These pregnant mothers don’t expect problems with their births and therefore don’t see the need to see a midwife.
The decision whether or not to seek a midwife is often made by the husband or the in-laws of a pregnant mother, who might have very little understanding of what possible dangers might ensue. They might not be aware of the benefits using a midwife. They even may not be prepared to expend the resources or take the trouble to see that the woman is properly attended. This situation can occur anywhere in Indonesia, even in the big cities, but is more prevalent in remote and poor villages.
PNPM Generasi is making sure that all children at least finish primary school and that mothers themselves don’t die or suffer health issues during or following birth. One of the main goals of PNPM Generasi is to reduce the infant mortality rate across Indonesia. PNPM Generasi realizes that each area in Indonesia has its own challenges and problems, and therefore different solutions should be applied to different cases. For this reason, PNPM Generasi provides funds at the sub-district levels for PNPM facilitators to identify the most severe problems in the area and find solutions. The facilitators will work with community groups, health and educational agencies, as well as service providers.
In the Cibitung Sub-district, Sukabumi, West Java, PNPM facilitators and local health agencies noted that more children died in Ciroyom Village than in any other villages in the sub-district. In 2011 alone, six young children died in Ciroyom, most during or soon after birth. In 2012, seven died there. The village did poorly according to other indicators measuring infant and maternal health, such as the rate of stunting, vaccinations, and the number of births attended by qualified medical personnel.
“The village is about 25 kilometers away from the nearest community health center. Villagers must spend two hours to reach the community health center by boat. They also have to drive a motorbike or a truck that is suited for driving on rough roads. If the tides are high, or if the day is rainy, they can’t travel. There is no regular boat service. Villagers have to rent a boat. This is why it’s too expensive for most villagers to make a trip out of their village. They won’t do it unless they feel they have to. The isolation and the poverty make medical care provision difficult,” said Rudy Malik, the PNPM sub-district facilitator.
Rudy said that the health agency has tried many times to post a midwife in the village by employing health workers who have just finished their schooling. They are required to work at community health centers at a low salary for a period of time in order to complete their formal qualifications. But the position of midwife remains vacant in Ciroyom. There have been cases where the assigned midwife left before her contract was fulfilled.
“No one wants to be posted there. There’s no electricity, it’s cut off from the rest of the world, and the people there are poor and uneducated. In the larger villages there are plenty of opportunities for midwives to make extra money through private practice. There is practically no prospect of that in Ciroyom,” Rudy said.
With the high cost and the difficulties of travel, for most a trip outside the village is a very rare event. Without resident health workers, many villagers will never receive formal medical services.
“I’ve only been to the sub-district center a handful of times in my life. The last time I went was to vote in the presidential election. I’ve never visited a hospital or had a consultation with a doctor. I’ve had three children by myself, but two of them died. One was stillborn, the other seemed healthy when I delivered her, but when I checked on her the next morning she wasn’t breathing,“ said Oyah, a 28-year-old mother who works as farmer and a volunteer health worker.
Without a qualified midwife available at the time she gave birth, Oyah, like almost all the other pregnant mothers in her village, was attended by a paraji, or traditional birth attendant. Mrs. Emur, a respected paraji, describes her role in the village.
“I’m 63 or 65 years old. I’m not sure of my exact age. I’ve helped countless women deliver their babies, the number is more than I can remember. Some of the babies I helped deliver are now grandmothers themselves. Some of the babies died. God decides which baby lives or dies. I help the woman giving birth by holding her hand and praying while she’s delivering the baby. Then I take the placenta and bury it in the ground, with a ceremony,” said Emur.
“A paraji might be able to help with an uncomplicated delivery, but they don’t have the competency to deal with an emergency. That’s why official health agency policy is that a birth should always be attended by a qualified health worker. Paraji can play supporting roles, such as providing psychological support, and acting as mediators between health care workers and the pregnant mothers, to explain procedures and ensure that the women follow the proper protocol,” Rudy said.
Of course, for all this to work there must be an available midwife. Rudy explains how he and the officials of the health care agency have used funds from PNPM Generasi to fill the long-vacant position in Ciroyom.
“We decided to recruit a midwife and pay her a very significant income of Rp3 million per month for accepting such a difficult post. The health agency played a major role in the recruitment process, advertising the position through its network of community health centers," said Rudy.
Candidates had to pass a range of tests, including a psychological test to determine their suitability to living in a remote, difficult location. The successful candidate, Elin Martiana, was given a 12-month contract beginning in 2013,” Rudy stated.
According to Rudy, since Elin Martiana was deployed in Ciroyom there has been only one recorded death of a new-born baby. In addition to reducing the number of infant mortalities, the midwife is providing many other vital health services. Since she has been there the number of children suffering from stunting has gone down, and the number of children receiving vaccinations and supplements has increased. Also on the rise is the number of women breast feeding their babies properly and the number of women attending health counseling and socialization sessions.
Rudy explained that PNPM Generasi has agreed to provide payment for the midwife to stay in the village for at least one year, and possibly two. So, what happens after that?
“PNPM Generasi helps to identify needs and possible solutions, and to test new approaches that have not been tried by the health agency. If we can show that a new approach works, district governments and their agencies can continue these initiatives and implement them as part of their core programs. In that way, the impact of short-term projects funded through PNPM Generasi can be sustained over the longer term,” Rudi said.
Midwife, Ciroyom, Cibitung
Even after midwife Elin Martiana arrived in Ciroyom, it wasn’t easy to make a change happen. Just because a midwife was available, it didn’t mean everyone thought it was necessary to use her services. Elin describes the challenges she faced, which included extremely difficult operating conditions, community attitudes, and the difficulties of living in a remote place:
This is my first time to live and work in a remote area. I sleep in the health care post itself. There’s no electricity in the village. When I have to deliver a baby at night, I use a battery-powered lamp. Getting clean water is also difficult. I’m the only health worker in the community, so apart from looking after women and children I have to provide first aid in the case of accidents or other emergencies. That’s not usually part of a midwife’s job.
I don’t have any reliable support system if something goes wrong. Just last week, I was assisting a mother who had a very small frame. The baby was large and she was having difficulties. She was in labor for hours. I thought we were going to lose both the mother and the child. Luckily, the weather was good and a trader with a jeep was visiting the village. We were able to bring the mother to a health post in another village with better facilities. We were able to save them both.
At first, the community didn’t really accept me. I’m only 21 years old, and a lot of people here didn’t take me seriously. At first, a lot of the mothers didn’t even come to the health care post for regular check-ups. However, the situation is beginning to improve. I’ve worked with the village head and the primary school teachers to make people more aware.
Before I came here, meetings at the health care post were run by the volunteer health workers. Often the meetings were cancelled or delayed, so the women didn’t think the meetings were important. I’ve made sure that the meetings are held regularly and are punctual. I’ve also organized the volunteers to knock on doors to invite women to the meetings. I try to work with paraji, the traditional birth attendants, to keep track of the community and to tell me when a woman is about to give birth.
I took the job because I always wanted to use my skills that I had learned to help women. The women here really need help. And the compensation offered for the position was quite attractive. Before coming here, I worked in Jakarta for a while. I felt more isolated there than here. It was very expensive to live in Jakarta, and there was a lot of competition as there were many midwives. It was hard for a fresh graduate to find work. My family lives in Sukabumi, so I can visit them quite easily from Ciroyom (short distance). I would take another job in a remote area, if the community needed me and if the health agency was willing to send me there.