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Reducing maternal mortality in Indonesia of post modern era

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 Reducing Maternal
Mortality
In Indonesia of Post Modern Era

Gaurav Daga, Strategic Asia, Indonesia.

August 2013

Reprint requests and correspondence should be addressed to PT. Strategic Asia | Graha Mandiri 28th
Floor, Jl. Imam Bonjol No. 61, Jakarta 10310

T : +62 21 315 1797 | F : +62 21 315 5712 | www.strategic-asia.com

 Table of Contents

Executive Summary ........................................................................................................................ 1

• Problem statement ...................................................................................................... 2

Introduction .................................................................................................................................... 3

• Background ................................................................................................................ 3

• Present situation .................................................................................................... 3

• Causes of maternal mortality ................................................................................. 4

Conceptual linkage ......................................................................................................................... 7

• Gender equality ...................................................................................................... 7

• Public service delivery ............................................................................................. 7

• Inclusive growth ..................................................................................................... 8

Findings supporting high maternal mortality rate in Indonesia ..................................................... 9

1. Due to gender bias policies and law:

• Early marriage (Child marriage) .................................................................................. 9

• Sexual and reproductive education in schooling.......................................................... 11

• Other than school based education .................................................................... 14

• Tackling courts to reduce maternal mortality .............................................................. 14

• Other gender policies and law .................................................................................... 18

2. Further issues:

• Midwvies and community ......................................................................................... 18

• Social and cultural traditions of Javanese people ............................................... 21

Reducing Maternal Mortality ii

• Transportation system and technology ....................................................................... 24

• Road transportation system ............................................................................... 25

• Mobile technology ............................................................................................ 26

3. International policies:

• International policies ................................................................................................. 27

• Factors for choosing five international countries .................................................... 29

• Percentage of public health expenditure with respect to GDP spending .................. 31

• Policies implemented by these five international countries ..................................... 33

• Lessons learnt from international countries for Indonesian policies ........................ 33

• Post MDG 2015 ................................................................................................... 34

4. Impeding challenge:

• HIV and Maternal Mortality - Can we find a correlation? ........................................... 35

Inference ....................................................................................................................................... 37

Biblography ................................................................................................................................... 38

Appendix ...................................................................................................................................... 42

Reducing Maternal Mortality iii

 List of figures and tables

Figures:

1. Trend of maternal mortaltiy in Indonesia ........................................................... 3

2. Provincial chart of Indonesia with respective to maternal deaths ......................... 5

3. Kinds of work offered by Midwives ................................................................... 18

4. Varation of range in maternal mortality ............................................................. 19

5. Trendline of maternal mortality over the years 1990-2010 .................................. 28

6. Trendline of public health expenditure (% of GDP) over 1995-2010.................... 30

7. Trendline of HIV infected people in Indonesia. .................................................. 31

Tables:

1. Survey on ideal age for marriage ........................................................................... 10

2. Empowerment program for midwives and shaman’s partnership ........................... 23

Reducing Maternal Mortality iv

 Gaurav Daga
Strategic Asia
Indonesia
August 2013

Reducing Maternal Mortality

In Indonesia of Post Modern Era

Executive Summary:

This policy brief aims to study the reasons behind high maternal mortality rate in Indonesia
through levitating a question of whether there exists a gender bias in various existing policies
implemented by the government? If there exists no biasness in the policies, then this report tries
to find out the factors supporting high maternal mortality in Indonesia.

Research for this policy brief included review of various literature based on issues like maternal
mortality, infant mortality, human development, sex-disaggregated data, existing health care
system, midwives, Indonesian laws and policies.

The major findings indicate that while there is a need for some caution on existing policies
related to maternal mortality and women rights on gender bias. The reason of Indonesia
experiencing high pregnant women deaths cannot be solely blamed to bias in the policies. Lacks
of infrastructure, technology, being an archipelago country are some of its factors too. The
briefing does not, however, provide detailed guidance on to how to operationalize the right to
health in the context of maternal mortality but with the help this documentation of systematic
reasons behind high maternal mortality, we can advocate for policies to the ministry of health
departments that would ensure health committees and superintendents have the training,
information, and resources to incorporate gender identity and expression into these existing

Reducing Maternal Mortality 1

procedures and policies. This kind of interventions will protect dignity of a small yet very
important group, recognizing that human rights are framed for humans not majoritarian.
Empowering adults would help this group achieve economic, political and social freedom.

Problem statement:

This research tries addresses the issues of high maternal morality in Indonesia and seeks to
propose policies towards making a fair society by addressing women issues. Gender identities are
integral aspects of us and should never lead to discrimination or abuse. However, people around
the world face violence in their everyday lives and sometimes torture, even execution – because
of various reasons. Women have been a subject to arbitrary arrests under unjust laws, unequal
treatment, censorship, medical abuses, discrimination in health and jobs and housing, domestic
violence, abuses against children, and denial of family rights and recognition etc.

In recent years, there has been increased recognition that reducing maternal mortality is not just
an issue of development, but also an issue of human rights. Preventable maternal mortality
occurs where there is a failure to give effect to the rights of women to health, equality and non-
discrimination. Preventable maternal mortality also often represents a violation of a woman’s
right to life.

Reducing Maternal Mortality 2

 Introduction:
Background:

Good Governance and Human Rights are deeply correlated. The links between governance and
human rights where this brief is focused is organized around three key areas: gender equality,
inclusive growth, and public service delivery. Inclusive growth in this context means an equitable
allocation of resources with benefits incurring to every section of the society. To complement
inclusive growth, democracy and public service delivery provides desirable and effective settings
for development. On the issue of maternal mortality in Indonesia, the progress so far has been
significant but the perspective of this briefing illustrates how human rights – i.e. gender sensitive
issues and its factors can contribute new impetus, frameworks and strategies for reducing
maternal mortality. This brief does not solely focus on gender bias policies. It also examines other
crucial factors.

• Present Situation:

Fig 1 – Trend of maternal mortality in Indonesia (Source – UNFPA Indonesia) 24

Reducing Maternal Mortality 3

In 2012, about 220 women per 100,000 died due to complications of pregnancy and childbirth,
including severe bleeding after childbirth, infections, hypertensive disorders, and unsafe
abortions. The risk of a woman in a developing country like Indonesia, dying from a pregnancy-
related cause during her lifetime is about 25 times higher compared to a woman living in a
developed country. Maternal mortality is generally regarded health indicator that shows very
wide gaps between rich and poor, both between countries and within them. But Indonesia is
unique in its say; the reasons for alarming maternal mortality range from social barriers to
gender bias to lack in access to medical facilities.

• Causes of Maternal Mortality:

Globally, around 80 per cent of maternal deaths are due to obstetric complications; mainly
hemorrhage, sepsis, unsafe abortion, pre-eclampsia and eclampsia, and pro- longed or obstructed
labour.9 Complications of unsafe abortions account for 13 per cent of maternal deaths
worldwide, and 16 per cent in regions of Southeast Asia that have highly restrictive abortion laws
(including Indonesia) 26

There are many varied causes for high maternal mortality but Figure 2 highlights some of the
alarming challenges in areas such as Java.

Reducing Maternal Mortality 4

 Provincial chart of Indonesia with respective to maternal deaths

Fig 2 - Provincial chart of Indonesia with respective to maternal deaths (Source - Ministry of maternal health – interactive
data management (Star planet)) 25

Reducing Maternal Mortality 5

Having examined the provincial rate of maternal mortality in Indonesia. Some of reasons for
high maternal mortality in general and in java are because of

• Indonesia, being an archipelago

• Political economy problem
• Economic development
• Access to metropolitan city i.e. Jakarta

But the crucial issues for high maternal mortality rate in Indonesia in spite of being one of the
fastest growing countries are

• Child Marriage: Underage pregnancy

• Lack of education on sexual and reproduction process in schools
• Lack of women’s access to courts
• Lack of good transportation system
• Lack of role of midwife community

Some of the secondary reasons for high maternal mortality can be

• Short period between pregnancies

• Lack of prenatal health care
• Migraine problems to women while/after birth

Furthermore, poverty, gender, inequalities, a lack of information, weak health systems, social and
cultural barriers are other obstacles that need to be overcome if women are to access technical
services and information that can often prevent maternal mortality and morbidity.10

Reducing Maternal Mortality 6

Conceptual Linkages:

• Gender equality:

One of the main reasons behind high maternal mortality is the failure to guarantee women’s
human rights. This is often manifested in, among others, low status of women and girls, poor
access to information and care, early age of marriage and restricted mobility. Gender equality
has an important role to play in preventing maternal mortality. Gender equality and
empowerment lead to greater demand by women for family planning services, antenatal care and
safe delivery. The Convention on the Elimination of Discrimination Against Women (CEDAW)
provides that States Parties “agree to pursue by all appropriate means and without delay a policy
of eliminating discrimination against women” and that they “shall take all appropriate measures
to eliminate discrimination against women in the field of health care in order to ensure, on a
basis of equality of men and women, access to health care services, including those related to
family planning.” 10

• Public service delivery

Public service delivery is one of the key domains in good governance and democracy. For
effective economic growth, investment in human capital is essential; in this case - mothers. There
is no ‘one policies’ for achieving effective public service delivery, but strong commitment to
reduce maternal mortality is vital. Active governments with strong leadership commitment to
human capital investment will increase the wellbeing of the family and in turn the country.

• Inclusive growth

Indonesia’s development model is taking its shape. Slowly if not always surely, it has improved
some parameters of inclusive development. However, in order to reduce disparity and promote
inclusive growth, setting targets for different parameters, such as gender gap in literacy rate,
infant mortality rate and maternal mortality is important to prevent social ramifications. This

Reducing Maternal Mortality 7

brief focus on the need to build inclusive Indonesia by giving access to health rights for women.
Maternal health is important because it sets the scene, not only for survival and subsequent
health of the infant, but also for the woman herself.

Reducing Maternal Mortality 8

 Findings supporting high maternal
mortality rate in Indonesia:

§ Early Marriage (Child Marriage):

Child marriage is a violation of a girl's rights, and has a devastating impact on her everyday life.
Early Marriage puts an end to a girl's childhood, her education, her freedom and her contact
with friends; family and more importantly the vulnerability of become pregnant. She becomes
often becomes a subject of abuse and neglect from her husband and his family as hers becomes a
life of domestic drudgery. Girls in some cultures are forced to marry much older men or men
with other wives. An early pregnancy leads to problems in heath and often carries high chances
of death. UNFPA Indonesia found that ‘early marriage leads to the initiation of sexual activity
during a period when girls know little about their bodies, their sexual and reproductive health,
and their right to family planning’. In Indonesia, sexual and reproductive health education is
scarce and this leaves young women ill prepared to enter adulthood, much less marriage or
childrearing. In some countries, girls are married as children: in parts of Africa and Asia over a
quarter of girls are married before the age of 16. 15

In Indonesia, Child marriage or early marriage is one of the critical areas where maternal
mortality still exists. In 2007, Demographic and Health Survey found that around 22% of girls
marry before the age of 18.21 One of the factors, which favor’s girls to marry early is the martial
act law. Indonesian government imposed Marital Act law that sets the minimum legal age for
marriage at 19 for males and 16 for females.

Marriage which sets the marriageable age at 19 for men and 16 for women is contradictory to
international obligations on the elimination of child marriage especially the provisions of
CEDAW*1 and the Convention on the Rights of the Child*2 that consider early marriage and

*1 See appendix for more details on CEDAW rectification and status report on Indonesia

Reducing Maternal Mortality 9

early pregnancy as a harmful practice. Additionally, in the context of equality between women
and men, the CEDAW calls states to take appropriate measures to eliminate discrimination
against women in all matters relating to marriage and family relations and in particular that
women have the same right to enter into marriage as men but nothing has been done in this
regard. Furthermore, the Convention on the Rights of the Child sets the minimum age of
marriage at 18 years equally for girls and boys. All these principles are translated into the Child
Protection Law that considers anyone below 18 to be a child and require the parents to be
responsible and accountable for preventing under-age marriage (Article 26). However due to
various factors, in Indonesia, it is possible and legal to marry before 16 with an official
dispensation from the Religious Court or a government officer to get married. That is why the
Law on Marriage is contradictory to international commitments and national laws that require
equal rights to enter into a marriage and sets the minimum age of marriage at 18 years equally
for girls and boys. Interesting, Indonesian government outlines that Child Protection Law*3
defines childhood as extending up to 18 years of age.

Recently, Ministry of health and BPS published out a preliminary report on adolescent
reproductive rights and found out that younger people both in urban and rural prefer to get
married around the age characteristic of 20-24, which supports the argument of raising the law
on age of marriage to 18 for both men and women. This means minimum 18 years of age for
everybody, even with official exemption. Table 1, shows the Survey on ideal age for marriage
according to background characteristic.

*2 See appendix for more details on Indonesia’s convention on the Rights of the Child

*3 See appendix for more details on Indonesia’s child protection law

Reducing Maternal Mortality 10

 Table 1: Survey on ideal age for marriage by never married men and women (Source - IDHS 2012)

§ Sexual and reproductive education in schooling:

The development challenges faced by young people and indeed all of society are varied and
interconnected in so many ways to maternal mortality. The challenges of health, education,
human rights are all central to the holistic development of individuals. Considering, hundreds of
women die every year through childbirth in Indonesia and the fact that many of them are young
women gives cause for us to examine all options available to us in stemming this tide.

Another area, which can help in reducing maternal mortality, is the education sector. It has a
critical role to play in preparing children and young people for their adult roles and

Reducing Maternal Mortality 11

responsibilities (Delors et al., 1996) 16; the transition to adulthood requires becoming informed
and prepared with the appropriate awareness and understanding to make responsible choices in
their social and sexual lives. More than 45% of women aged 20–24 married by age 18, have 1-2
children.38 Moreover, Statistics from 2008 revealed that 36.6% of Indonesian marriages involved
people aged 16 and under, making the setting even more important as an opportunity to provide
education about sexual and reproductive health. In most countries including Indonesia, children
between the ages of 5-13, in particular, spend relatively large amounts of time in school. Thus,
schools provide a practical means of reaching large numbers of young people from diverse
backgrounds in ways that are replicable and sustainable (Gordon, 2008) 16. School systems benefit
from an existing infrastructure, including teachers likely to be a skilled and trusted source of
information, and long-term programming opportunities through formal curricula. School
authorities have the power to regulate many aspects of the learning environment to make it
protective and supportive, and schools can also act as social support centers, trusted institutions
that can link children, parents, families and communities with other services (for example, sexual
education).

In 1979, Indonesian government implemented Law no.2/1979, which made nine years of
obligatory education for children’s. It would appear appropriate to add the importance of
reproductive health and gender education during these nine years into this law for education.
Policymakers begun to discuss the mainstreaming of gender concepts in the curriculum; but
discussions on reproduction education still remains in prefatory stage. Preliminary materials have
been developed by the National Center for Physical Quality Development in the Ministry of
National Education but nothing significant has been done yet. The 2013 report on gender
mainstreaming by ministry of education and other departments concluded that there are
numerous challenges in achieving gender mainstreaming. One of the topics, which the report
fails to incorporate, is about reproductive health and gender concepts in the school curricula.
Given that unsafe sexual behaviors persist because of, at least in part, limited information and
knowledge on sexuality and reproductive health. Inclusion of this information is also important
given that harassment, sexual assault, and crime continue as a partial result of a deep gender gap
between females and males. 19

Reducing Maternal Mortality 12

Various societal structures support a detrimental image of women. Ideologically, the state views
Indonesian women as the nurturers of their offspring, their husbands, their communities, and the
state. To a real extent, women’s sexuality and reproductive health are regulated by the state.
Family planning campaigns and practices are mostly targeted to women. 22

If reproductive health and gender education were included in school curricula, future generations
would have a better understanding of reproductive health, sexuality, and gender. As a result, the
upcoming younger generations would understand the risks involved in these important matters of
their life. Shared responsibility of reproductive health matters by males and females would also
be made a greater possibility.

Evidence from UNESCO, WHO, UNICEF and the World Bank (WHO and UNICEF, 2003)
point to a core set of cost-effective legislative, structural, behavioral and biomedical measures that
can contribute to making schools healthy for children. While the help of International Technical
Guidance for school setting, much of the maternal deaths below 18 can be prevented.

Effective sexuality education will among other things:

• Reduce information asymmetric;

• Increase correct knowledge;
• Clarify and strengthen positive morals and attitudes;
• Increase skills to make informed decisions and act upon them;
• Improve perceptions about peer groups and social norms; and
• Increase communication with parents or other trusted adults and lot more.

Other than school based education:

Other ways to educate people on reproductive health to reduce maternal mortality can be
provided through

1. Community-based teaching

Reducing Maternal Mortality 13

 2. Workplace education
3. Civil society empowerment and engagement
4. Peer approaches
5. Youth centers
6. Mass media – TV, Radio, Internet
7. Fliers

§ Using court to reduce Maternal Mortality

In Indonesia, the religious courts are an important avenue for women seeking the path to justice.
Out of the three division of Indonesian constitution, judicial system is one of the key power
holders. It is judiciary, which upholds the laws of land. The constitution empowers courts with
judicial review under which courts can declare laws as null and void, which are ultra vires.
Judicial review was necessary in order to give effect to the individual and group rights
guaranteed. Judicial review of Indonesia courts has evolved over many dimensions – some of
them are,

§ To ensure fairness in administrative action,

§ To protect the constitutionally guaranteed fundamental rights of citizens.

However, It has been seen that women are often denied justice in courts because of the two main
reasons,

§ Corruption and
§ Lack of gender sensitization for judicial officers

Maternal mortality, Infant mortality, morbidity is not only important for women’s rights within
the family, it is also essential for accessing public services. Marriage certificates are often needed

Reducing Maternal Mortality 14

to obtain birth certificates for children, which are required to register for school and to claim
inheritance rights.

A survey by the women’s NGO PEKKA - Pemberdayaan Perempuan Kepala Keluarga (Female
headed household empowerment), found that one third of PEKKA members living below the
poverty line reported difficulties accessing benefits and services such as free health care and cash
transfer programmes. Religious courts handle 90% percent of all legal divorces in Indonesia;
hardly cases related to health issues of women are discussed in these courts. To add a layer, the
costs can be prohibitive for women. The average total cost of obtaining a judgment through the
religious courts is $90 or 800,000 Rupiah; almost four times the monthly income of a person
living on the poverty line. 27

Lack of awareness of rights is also a problem. To empower local communities about their various
entitlements, a roadmap for change is needed. A map of progress and the routes to travel to
achieve their claims i.e. mapping of the theory of change that leads to legal empowerment. As
Mancur Olson points out in one of his books that when empowering communities, people tend to
act for individual rationality and try to maximize its utility, so unless and until there is some
coercion the logic of collective action, claims to entitlement would not be achieved.

Possible direction for empowerment:

Here, we are interested in empowering communities for their claim towards health services
related to women on midwives, prenatal care, family planning, contraception etc.

One of the way to empower people towards their public will, towards their rights, towards their
increase in knowledge, towards their shared commitment to a common vision for the community
is through a training program. Various research have found that the reason behind the
disconnect of the law in theory and law in practice is because of two reason

§ Because of a lack of good governance; and

§ Lack of effective citizen participation, which will assist in the development of sustainable
good governance practice

Reducing Maternal Mortality 15

The first step in helping villagers become active participants in democratic governance is
selecting trainees for the experiment, in this case on issues related to maternal mortality. Trainees
are selected through a simple and participatory process. Any adult villager who is willing to
commit to the training is eligible to participate. The focus on women‘s participation eventually
plays a significant role in the success of the experiment.

The training begins by making the trainees aware of their rights and entitlements, and then
through this awareness, we enable them to participate in the awareness-training program in their
village. When the villagers utilize information received in the classroom in the real world, they
learn by doing, and as a result, they encourage good governance in their villages. Yet, another
objective that the experiment achieves is increasing villager’s belief and confidence in what they
have learned. When they apply the information received in the classroom, the villagers realize
that this information works and that there is no disconnect between theory and practical
application.

To map out our theory of change, the objectives of the reducing maternal mortality will be

§ To improve the nutritional and health status of pregnant mothers

§ To lay the foundation for the proper psychological development of their child;
§ To reduce the incidence of mortality, morbidity, malnutrition,
§ To achieve effective coordination of policy and implementation among the various
departments to promote child development; and
§ To enhance the capability of the mother to look after the normal health of the child
through proper nutrition and health education.

One of the benefits of having this rights awareness program is that we report to the trainees
about the non-functional areas related to reducing mortality. The trainees organize meetings
with the people who are responsible for public service delivery of these policy programs i.e.
government officials, stakeholders. Using the information that the trainees receive from the

Reducing Maternal Mortality 16

beneficiaries of various existing policies and the problems that are related to that are reported to
the officials. The trainees prepare a multi-pronged approach to serve the clients. This approach
includes writing complaints; using the right to information to ascertain the status and action
taken on those complaints; invoking appropriate jurisdictions in consumer forums, quasi-judicial
bodies, and other forums for redressing grievances; and organizing panel discussions with senior
government officers and policy makers to discuss issues requiring further debate and policy
intervention.

This methodology and pattern is used throughout the experiment in all areas of intervention and
the corresponding outcomes/improvements/indicators can be regarded as the theory for change.

The right to information is used in the experiment as a tool for villagers to participate in the
affairs of rural governance. In addition to training the villagers, the legal empowerment approach
includes:

§ Preparation of legal literacy material in the native language for wider dissemination;
§ Organizing legal literacy events for the villagers;
§ Organizing panel discussions bringing government officials and policymakers face-to-face
with villagers;
§ Representing public interest litigation and concerns of villagers at appropriate forums;
and
§ Making policy interventions

Thus, if communities benefit from the outcome of their engagement with the empowerment
program regarding maternal mortality then they will be motivated to strengthen that
engagement. Subsequently, it is through this motivation and engagement that communities
develop faith and confidence in law, its promises, and its processes.

Reducing Maternal Mortality 17

 § Other Gender Law and Policy

1. Law No. 10/1992 restricts family planning services for single parents. In particular,
regardless of one’s marital status, men and women should have equal rights to family
planning and reproductive health information and services. Shared reproductive health
responsibilities between men and women should be encouraged from early adolescence
and again before the entry to marital life.

2. Law No. 23/1992 defines abortion as illegal even though it is public knowledge that
abortions are widely provided in Indonesia by both medical and nonmedical personnel.
Article 15, Section 2, paragraph (1) states, “In the case of emergency, and with the
purpose of saving the life of a pregnant woman or her fetus, it is permissible to carry out
certain medical procedures.” Hence, it is only if a woman’s life is in danger that an
abortion can legally be performed. This helps explain why young women who have
become pregnant outside of marriage often turn to traditional healers or other
nonprofessional health practitioners when they seek abortions who are not qualified
enough to perform such activities. So institutional reforms are necessary in implementing
this law.

Further issues:

§ Midwives and community:

Midwives are professionals, responsible and accountable women, who work as partners to
provide support, care and advice during pregnancy, childbirth, postnatal period, facilitating
childbirth on their own responsibility and more. Midwives take care of preventive measures such
as promotion of normal birth, the detection of complications in mother and child, access to
medical assistance or other appropriate assistance. They play an important role in health
counseling and education, not only to women, but also to their families and communities. Things

Reducing Maternal Mortality 18

like; antenatal education, preparation for parenthood, women's health, sexual health or
reproductive health and child care.

Midwives can provide services in various places: including home, community, hospital, clinic or
other health units. Figure 3 shows the different kinds of services offered by midwives.

Fig 3- Chart of different kinds of work offered by Midwives

The village midwife is a central element of Indonesia's strategy to improve maternal and child
health and family planning services. Going back at the history, there has been closure and
reopening of the midwives program many-times in its institutional setup. Recently there has been
concern that the midwives were not present in the villages to which they had been assigned.

Reducing Maternal Mortality 19

Figure 4 displays provincial maternal deaths in Indonesia. It should be noted that the whole
province of java i.e. west java, east java, central java and banten has significantly high maternal
deaths compared to other provinces.

Fig 4 – Range of maternal mortality in different provinces of Indonesia (Source – StarPlanet – Ministry of Health interactive
data management) 25

The reasons for Java experiencing high rates of maternal mortality can be many but one of them
is midwives. Recently BMC research notes published an academic paper to determine the extent
of village midwives in three districts in West Java Province, Indonesia. It found out that there has
been concern regarding midwives being not present in the villages to which they had been
assigned. To add a layer, health problems for residents in cities and in rural Indonesia are still a
thorny problem. This can be seen from the many health programs are implemented and
continue to be developed not run well, be it a new health program or health program modified

Reducing Maternal Mortality 20

old program. Inadequacies still exists in many health care area. One of the reasons is that
midwives are not present where they are assigned because of people’s misperception of their
activities. Javanese social and cultural traditions contribute to maternal mortality.

• Social and cultural traditions practiced by Javanese people

Javanese people still prefer to aid deliveries by Traditional Birth Attendants (TBAs) because of
social and cultural reasons. In fact, almost all Indonesian people living in both rural and urban
areas prefer to be helped by the soothsayer (who are TBA’s). This was caused by the local
customs and traditions. Soothsayers (One who claims to be able to foretell events or predict the
future) - are still preferred by rural and to an extent urban communities to help them during
women’s delivery. Because of people’s preference for soothsayers, it is impossible to eliminate role
played by the old system of health with treatment of the new health system. The current
education/empowerment program given to soothsayers is non-effective.

Modern science has evolved drastically in the last decade. Traditional practices to any medical
treatment are termed as old concept for many good reasons. However, some health programs
have failed because of trying to run solely by referring to the medical technical considerations
'rigid'. One program that has not reached the target, as expected, is the delivery assistance.
Almost in all of Indonesia, TBAs attend for childbirth.

Both in rural and urban areas, shaman (soothsayers) leaders are considered influential because of
the power and the authority they command. As Max Weber distinguishes authorities on three
key domains, shamans are considered as having charismatic authority, for the ability or authority
that are special to god.

TBAs ability is generally acquired through hereditary process. Some of their characteristics are,

§ Ordinary people,
§ Education does not exceed much; generally illiterate,

Reducing Maternal Mortality 21

 § Work as a shaman (TBA) is generally not for the purpose of making money but due to
'demand' in order to help others,
§ Being a shaman (TBA) is not their profession, they generally have other jobs too
§ Highly respected and influential figure.

To overcome the short term benefit to reduce maternal mortality is to educate and harness the
existing TBAs immense significance and role in aid delivery. Theories of medical anthropology
help us understand 1) the relationship between health workers, shamans and society, 2) the idea
and concept of life and death, nature and shaman and embraced by the public as well as beliefs
about the causes of illness and death in infants and new mothers, 3) medical practice performed
by doctors, midwives and nurses.

• Possible policy direction

Indonesian government seemed to have done not much in this regard. A possible way or strategy
to build a cohesive network (cooperation) among local leaders, communities, traditional healers,
and midwives in implementing maternal and perinatal health services is through partnership.
One of the strategies to deal with social and cultural barriers is to use the impact evaluation
process. Government can develop a program, which intends to reduce maternal, infant mortality
and achieve better health outcomes by enabling an empowerment and partnership program
between midwives and shamans.

This partnership program means when a patient is about to maternity, the shaman shall call the
midwife. At the time of delivery assistance, no division between the role of the midwife or
shaman will be made. The role of the midwife and healer is concerned with childbirth and the
post-natal. At the time of delivery, the role of the midwife portion is greater than the role of the
shaman. In addition to attending births, midwives can also give injections to patients who need it
or can refer to a hospital immediately if any critical or difficult births. Their role was limited to
helping midwives such as stroking the patient's body, providing drinking when the patient needs

Reducing Maternal Mortality 22

and the foremost is to give inner strength to patients. TBAs presence is important because
patients assume that if childbirth attended by a shaman, then delivery will go smoothly.

Moreover, the shamans are usually those who are very close to the people, so they usually know
in advance if there are pregnant. In addition, sometimes people also still needs the presence of
the shaman to help them, especially after childbirth is completed to help clean the house, bathe
the baby as well as reading the mantras. The empowerment program for TBAs, community
leader, mothers will complement the provision of health knowledge; will reduce labor, increase
the risk of infant survival and mother. Table 2 shows a possible strategy for empowerment
program.

EMPOWERMENT PROGRAM
Level Indicators
Inputs • Funds
Activities • Midwifes training
• TBA’s training
• Shaman community leaders contacted
• Mother’s group meeting
• Radio announcements
• Fliers put out
Outputs • Trained Midwifes
• Trained TBA’s
• Partnership between TBA’s, midwives and community
leaders
• Monthly Mother’s Group Meeting
Intermediate outcomes • Pregnant women reached
• Women attending the MG meeting
Final Outcomes • Women with greater knowledge and better practice
• Safe delivery

Reducing Maternal Mortality 23

Impact • Better Health
• Lower MMR
• Lower IMR and healthier children’s
Table 2 – Empowerment program for midwives and shaman’s partnership

The program will be considered in the preparation of training programs so that knowledge and
technology are drilled into the local population.

Generally changing people’s attitudes and behavior towards village midwives takes time. The
partnership is crucial because - Shamans are known for their magical spirits to ease out women
during delivery and midwives have the expertise in delivery. The role of traditional birth
attendants will help people understand the importance of midwives. From the concept of ‘three
delays' *4, one of the factor causing maternal and infant mortality is delay in decision making by
the family. So it was natural to happen maternal and infant mortality as a consequence of delays
in initiating the decision by the family, the community and the shaman. Partnership between
TBA’s and midwives will led to quick responsive measures for mothers in order to reduce
maternal and infant mortality. This approach will be especially beneficial remote areas where
access to health services is very limited.

§ Transportation system and Technology:

The Interlink between good transportation facility, technological services and health are highly
correlated to each other. In the case of maternal mortality, transportation sector affects the
availability of both preventive and emergency care, potentially affecting service delivery rates.
Good transportation system is essential for the distribution of drugs, blood and other supplies of
health care facility related to maternal health. It also enables the timely transfer of patients
between health facilities and to the different levels of care of health referral systems. Efficient

*4 As argued by Michael Winkelman, there are three barriers to the implementation or

application of a program in maternal mortality. The three delays are namely: 1) cultural
barriers 2) social barriers and 3) the psychological barriers.

Reducing Maternal Mortality 24

transport systems and mobile phones facilitate access by health workers to often sparsely populate
rural areas as well as the necessary monitoring and supervision of heath services and initiatives.

The World Health Organization (WHO) estimates that between 40 to 60 percent of the people
living in developing countries live more than 8 km from a health care facility. Although health
outcomes in Indonesia have drastically improved in the period of 1990’s but the progress slowed
down in the 2000s, and at the current pace, most provinces of the Indonesia will not reach the
desired level of Millennium Development Goals (MDGs) for Health by 2015.

World Bank’s Transport and Social Responsibility (TSR) Thematic Group review on linkages
between the transport and the health sector to reduce both child mortality and maternal
mortality, shows that particularly in rural areas, considerable time is spent by women and their
families waiting for transportation and traveling to a health facility. In addition, poor roads, too
few vehicles and high transportation costs are major causes of delay in deciding to seek and reach
emergency obstetric and postnatal care. Limited evidence, often restricted to a group of villages
or a district, makes overall comparisons between interventions and across the various levels of
referral difficult.16

• Facilitating good road transportation system:

One of the article on New York Times reported that “Lack of good roads also contributes to a
graver problem: maternal mortality. The benefit you get from these roads is an immediate cut in
maternal mortality’ said Scott Guggenheim, the Kecamatan Development Program's director.
Indonesia has one of the highest maternal mortality rates in the world. If the roads are flooded,
women die on the way to the hospital; they can't get through and they bleed to death. People
underestimate the importance of roads in Indonesia. You can't quantify the benefits.”4

In Indonesia, less than half of deliveries are attended by professional health staff in rural areas.
The right environment must support skilled attendants. Lifesaving interventions – such as
antibiotics, surgery, and transportation to medical centers – are unavailable to many women,

Reducing Maternal Mortality 25

especially in rural areas. There can be numerous reasons; women lacking the capacity but good
transportation system are crucial.

As seen, maternal mortality fell drastically in the US because of the easy transportation of
antibiotics and blood transfusion more than anything else. Various search show us that as long as
there is a system in place to transport women in labor to a facility within 30 minutes where there
are antibiotics, blood transfusion and cesarean section capacity, there should be very little
maternal mortality. *5

If midwives (traditional, direct entry, or nurse-midwives) are trained to know the signs of serious
complications and have the means of transport, there is no need for a doctor at the site of
primary care of pregnant and birthing women who have had no complications.

The transport lessons around the reduction of maternal mortality in Indonesia clearly involve
communication and organization issues as well as;

• Fast information links can save lives i.e. usage of mobile phones services like –
FrontlineSMS *6
• Rendering facilities locally can reduce the need for mobility, and
• Operating hostels for those at risk can temporarily reduce distance within critical windows
of care.

*5 Grieco, Margaret et all (2005) ‘Maternal mortality: Africa's burden - Toolkit on Gender,
transport and maternal mortality’, World Bank.

*6 FrontlineSMS – is mobile software, which helps in lowering the barriers to drive

transformative social change. It is built on open-source software to provide support and
resources to its users, and draw on users experiences to inspire others. More details –
www.frontlinesms.com

Reducing Maternal Mortality 26

Having established the importance of transportation for health services like maternal care, rapid
access to emergency obstetrical care, including treatment of hemorrhages, infections,
hypertension, and obstructed labor is crucial. It is also important to ensure that a midwife, or
doctor is present at every delivery.

• Mobile phone technology

By teaching the community health workers to send text messages containing medical information
back to the hospital staff, patients can receive emergency care. Community health workers can
save 1,000s of hours of travel time; which can be used to visit more patients, more treatment, less
consumption of fuel and many more benefits.

The government of Indonesia has already collaborated with FrontlineSMS firm, who focuses on
open-source applications for mobile mapping and health data visualization in remote rural areas.
Currently, it is only used in Nusa Tenngara Timur province.

Many areas in Indonesia have a landscape of rugged and infertile with a short and intense wet
season. In this environment subsistence farming, the predominant livelihood is marginal with
many communities experiencing periods of hunger through the dry season. The provision of
services to the rural population is difficult because there the few roads and they are generally of
poor quality and frequently impassible to visit. For many accessing health services requires
walking long distances and the use of public transport where available. It is not uncommon for
people in need of emergency care to be carried by a group of villagers to a point where road
transport is available. If this technological service is provided in such remote areas, maternal
mortality can be reduced drastically. Some of the remote areas are in,

• Southeast Sulawesi
• Central Sulawesi
• East Kalimantan
• West Kalimantan
• South Sumatra and some parts of Central Java

Reducing Maternal Mortality 27

 § International comparison:

Doing an international assessment on maternal mortality is fundamental in understanding the

policies implemented by other countries that share similar conditions as Indonesia does. There is
no single measure that summarizes the health or health care system of a country. More often, a
set of indicators reflecting certain aspects of health or a health system is used. However, as
maternal mortality has a common conceptual framework, direct comparisons of national statistics
across countries can be done. A country’s health system might be described using measures that
indicate the levels of access to services, the quality of health are, and health care costs.

A commonly used composite index is the Human Development Index, which summarizes a
country’s human development based on measures of life expectancy, literacy, education and
income. The index provides a way of grouping countries according to similar levels of human
development. Given the diverse nature of health care systems, preparing a comparable set of
health data requires common definitions of specific health concepts. International agencies
generally have collection of consistent data to track change, performance and progress towards
goals such as the UN Millennium Development Goals. Here, data from World Bank is used for
our analysis. Figure 5 shows the trend line of maternal deaths in Indonesia over the years 1990-
2010.

Reducing Maternal Mortality 28

 Trend line of maternal mortality over the years 1990-2010

Fig 5: Trend line of maternal mortality over 1990-2010. Source: World Bank Data 2013

Factors for choosing five international countries:

Indonesia is unique in its characteristics, the countries chosen for comparing maternal mortality
are based on the following,

1. India:

§ Shares similar trend line of decrease in maternal mortality

§ Comparable cultural and social traditions

§ Similar GDP growth rate

2. Philippines:

§ Being an archipelago country

Reducing Maternal Mortality 29

 § Population of Indonesia is just double of Philippines

§ Similar human development index ranking

3. Vietnam:

§ For the trend line or direction which Indonesia should try to follow from its current
position of 220 deaths per year

§ Similar human development index ranking

4. China:

§ For its remarkable achievement in below 100 maternal deaths in spite of being world’s
largest populous country

§ South Asian country

5. Maldives:

§ Being an archipelago

§ Muslim dominated country

Reducing Maternal Mortality 30

Percentage of public health expenditure with respect to GDP spending:

It is often considered good if a country spends at least 5% of its GDP on public health
expenditure. Figure 6, shows the trend line of ratio of GDP percentage on health for the six
countries including Indonesia.

Fig 6: Trend line of public health expenditure (% of GDP) over 1995-2010. Source: World Bank Data 2013

Comparing the figures of maternal mortality deaths and percentage of GDP spending on health,
it is seen there is a correlation between them i.e. more the spending on public health, lesser the
level of maternal mortality, infant mortality and morbidity. Ideally, it is recommended that a
government should spend around 5% of its GDP on health.

Reducing Maternal Mortality 31

Policies implemented by these five international countries:

1. China

Within the establishment of People’s Republic, China made remarkable achievement in reducing
maternal mortality by almost 90%. In the last 25 years, her effort in decreasing maternal deaths
has been applauding for numerous reasons. It has substantively improved access to hospitals and
emergency obstetric care. Within the system, the commitment for promotion and provision of
safe delivery services has also paid off. The “Decreasing Project” initiated by the government in
12 western rural provinces in 2000 aimed to decrease maternal mortality and eliminate neonatal
tetanus. Maternal emergency referral systems were strengthened, the quality of services was
improved, and targets for increasing institutional birth rates and improving service quality were
imposed. WHO data shows that institutional birth rates have risen substantially, particularly in
the western region, where institutional birth rates increased from a median of 58% in 2000 to a
median of 74% in 2005. 32 This increase undoubtedly accounts for a large proportion of the
observed decrease in mortality. Other factors like increased household income, one child policy
of Chinese government can be acclaimed for reducing the deaths. It is reasonable to assume that
families invest more in care for pregnancy and birth when such events occur only once or twice
in their lives. Presently, China’s spending on health is of the highest in Asia and has one of the
lowest maternal deaths (37) in the whole of south Asian region.

Indonesia in this regard needs to prioritize its policies towards health programs. The MDG target
of 102/100,000 and an estimated 10,000 women die each year due to complications during labor
and delivery is far from reach. Most of these deaths are preventable. The leading causes of
maternal mortality in Indonesia are hemorrhage (28%), eclampsia (24%), and sepsis (11%).
Almost 50% of maternal deaths take place where poor quality of care and delayed referral are
contributors to the factors. In short, institutionalizing childbirth is crucial in reducing maternal
mortality.

2. Viet Nam:

Reducing Maternal Mortality 32

Vietnam has done relatively well when considering urban access to maternal health services and
promotion of maternal health-related information. Studies show that in countries where maternal
health is a national public health priority, rates of maternal deaths are decreasing. For instance:
In Jamaica, maternal mortality rates declined from 600 per 100 000 births in 1930 to 100 per
100 000 births in 1980 and this is true for many western countries such as Britain and Sweden
too. Vietnam has been keen in developing national policies regarding maternal health and it has
done considerable in this regard.

3. Maldives:

Maldives achievement in health is remarkable. It has reduced maternal mortality deaths from
900 per 100,000 in 1990’s to less than 100 per 100,000 in 2010. One of the reason, it succeeded
in its reduction in maternal mortality, infant mortality and morbidity was because of its spending
on health with respective to its GDP earning.

Maldives devoted one of the highest percentage of its spending on health. Its average spending
was much higher than the normal spending of many countries in south Asian region including
China, India.

4. Philippines:

Philippines is not every much different than Indonesia in the context of maternal deaths, infant
deaths and population size. Philippines realized that to reduce disparities in health policies,
universal health care system (UHC) must be introduced. In 2010, UHC was introduced and
today it suffers only 99 deaths per 100,000 live births. Another unique effect to reach MDG goal,
was that it formed an organization of Community Health Teams (CHTs) in each priority
population area. CHTs are groups of volunteers, who assist families with their health needs,
provide health information, and facilitate communication with other health providers. Nurses
were trained to become trainers and supervisors to coordinate with community-level workers and
CHTs.

Reducing Maternal Mortality 33

Another effort was to provide the necessary services using the life cycle approach. These services
included family planning, ante-natal care, delivery in health facilities, newborn care, and the
Garantisadong Pambata (A biannual week long delivery of a package of health services to
children between the ages of 0-59 months old with the purpose of reducing morbidity and
mortality among under fives through the promotion of positive Filipino values for proper child
growth and development) package.

5. India:

By the introduction of Janani Suraksha Yojana in 2005, Indian government as did by Chinese
government institutionalized delivery of babies and reduction in maternal deaths. Indian
government made Janani Suraksha Yojana, a national health policy. It trained ASHA
(Accredited social health activists) workers and identified states (or provinces in Indonesian
context) based on institutional delivers and divided into low performing states and high
performing states. For every institutionalized childbirth, ASHA workers were given cash benefits
for her empowerment to local people on procedural deliveries.

For the effective monitoring of the scheme, monthly meeting of all ASHAs /health workers was
held. Reports were prepared for understanding the necessary improvements.

Lessons learnt from these international policies for Indonesian policies:

From the above international policies implemented by various countries, Indonesia needs to
focus on the following key areas,

• Institutionalizing child births

• Health policies – A national priority

• Facilitating mid-wives for childbirth assistance

• Need of higher percentage of GDP spending on health policies – At least 3-4%

Reducing Maternal Mortality 34

 • Implementation of child health program as done by Philippines, Maldives (under
deliberation) and India

It should be also noted that these five countries do not have any gender bias polices as outlined in
this brief for Indonesia.

• Post MDGs – 2015

Calculating human development index score involves three major components 1) Life
expectancy 2) Education and 3) Standard of living. Many times, to reflect country-specific
priorities and problems, global HDRs are tailored so that additional components are included in
the calculation.

Currently, Indonesia’s HDI value for 2012 is 0.629—in the medium human development
category—positioning the country at 121 out of 187 countries and territories. The rank is shared
with Kiribati and South Africa. Between 1980 and 2012, Indonesia’s HDI value increased from
0.422 to 0.629, an increase of 49 percent in total. Its life expectancy at birth increased by 12.2
years to 69.8 at present, mean years of schooling increased by 2.7 years, expected years of
schooling increased by 4.6 years and GNI per capita increased by about 225 percent between
1980 and 2012.

One of the components for life expectancy category is adjusted to reflect under-five or maternal
mortality rates. The current population of Indonesia is around 240million and the current
average maternal mortality rate is around 220,000. So if appropriate policies are undertaken to
improve mortality, then Indonesia can improve about .014 values in its HDI score and get a rank
of 117 or 118 from 121. Similarly, for gender inequality index too.

Impeding challenges:

• HIV and Maternal Mortality - Can we find a correlation?

The two top causes of death in women of reproductive age globally are HIV/AIDS and
complications related to pregnancy and childbearing i.e. maternal mortality, which account for

Reducing Maternal Mortality 35

19% and 15% of all deaths in women aged 15–44 years, respectively. In Indonesia, HIV/AIDS
has been increasing drastically and today it accounts for 0.3% of its population (around 70,000
people). Maternal mortality accounts for 35% approximately of the total deaths, which gives a
challenge for Indonesian government. The growing burdens of HIV infection in young sexually
active women and the maternal health problems that they face have been described as two
intersecting epidemics. In settings with increasing high HIV burden and high maternal mortality
ratios, especially in Indonesia, many are HIV-infected pregnant women are confronted not only
with the risk of death associated with advancing HIV disease, but also with an increased risk of
pregnancy-related death.

Fig 7 – Trend line of HIV infected people in Indonesia. Source: World Bank 2013 Data

Figure 7 shows us the increasing trend line of HIV infected people in Indonesia. The relative risk
of pregnancy-related death in women infected with HIV compared with that in non-infected
women ranges from just over double in one hospital-based study in South Africa. Although these
studies varied in size and quality, there is compelling evidence of increased risk of maternal death
in women infected with HIV. However, this correlation about HIV and maternal mortality is
relatively new area and not much work has been done yet. But with the increasing HIV rate, it
should be noted that a positive correlation between HIV and maternal deaths is highly possible.

Reducing Maternal Mortality 36

 Inference

What emerges clearly from this policy brief is that there are a few legal, regulatory, policy and
health system barriers exist which still are gender biased and few lack in the domain of public
service delivery which need to be addressed in order to accelerate progress towards reduction of
maternal mortality and morbidity. Examining these barriers in the context of Indonesia’s human
rights obligations under international and national law has demonstrated that action is required
to be taken by not only the Ministry of Health but also of a number of other governmental and
non-governmental actors, in collaboration with each other.

With the help this documentation of systematic reasons behind high maternal mortality, we can
advocate for policies to the ministry of health departments that would ensure health committees
and superintendents have the training, information, and resources to incorporate gender identity
and expression into these existing procedures and policies. This kind of interventions will protect
dignity of a small group, recognizing that human rights are framed for humans not majoritarian.
Empowering children would help this group achieve economic, political and social freedom.

Reducing Maternal Mortality 37

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Reducing Maternal Mortality 41

 Appendix

* Number 1: Laws and policies on gender in Indonesia

• Law no. 2/1998: National Education System: The nine-year compulsory education
program beginning in 1994. Parents are encouraged to send their children to school,
regardless of their sex, at least until they complete junior high school.

• Indonesia Demographic and Health Survey 2007 (IDHS2007) was a survey that
designed to provide information about fertility, mortality, family planning, and health.
Provide data concerning fertility, family planning, maternal and child health, maternal
mortality, and awareness of AIDS/STIs to program managers, policymakers, and
researchers to help them evaluate and improve existing programs. The next IDH2012
survey report will be released in August 2013

• CEDAW rectification and status report on Indonesia

INDONESIA
Date of Reservations Optional Reporting Status Coordinating Agency for
Accession / Protocol CEDAW
Ratification Implementation

29 July 1980 Article 29, Signed - Initial report examined at 7th session, Ministry of Women
(signed); 13 Sept paragraph 1 28 Feb 1988 Empowerment and
1984 (ratified) 2000, not - Combined 2nd and 3rd reports Child Protection
yet examined at 18th session, 1998
ratified - Combined 4th and 5th reports
examined at 39th session, 2007
- Combined 6th and 7th reports
examined at 52nd session, July 2012
- Next report due in 2016
Source: CEDAW in Action in Southeast Asia. http://cedaw-seasia.org/by_region.html

Reducing Maternal Mortality 42

 • Convention on the Rights of the Child, 20 November 1989.
Country: INDONESIA:

The 1945 Constitution of the Republic of Indonesia guarantees the fundamental rights of the
child irrespective of their sex, ethnic or race. The Constitution prescribes those rights to be
implemented by national laws and regulations. The ratification of the Convention on the Rights
of the Child by the Republic of Indonesia does not imply the acceptance of obligations going
beyond the Constitutional limits nor the acceptance of any obligation to introduce any right
beyond those prescribed under the Constitution. With reference to the provisions of articles 1,
14, 16, 17, 21, 22 and 29 of this Convention, the Government of the Republic of Indonesia
declares that it will apply these articles in conformity with its Constitution.

Source: (1992) Multilateral Treaties deposited with the Secretary-General, Status as at 31 December 1991,
United Nations, New York, p.201.

• Indonesia, Law on Child Protection, No. 23 of 2002

Article 2: The protection of children shall be based up on Pancasilia (the national ideology), the
1945 Constitution and the basic principles contained in the Convention on the Rights of Child,
including the following:

• Non-discrimination;

• The best interests of the child;

• The right to life, continuity of life and to develop;

• Respect for the opinions of children.

Source: January 2013, CHILD PROTECTION MODEL LAW - Best Practices: Protection of Children from
Neglect, Abuse, Maltreatment, and Exploitation, John Hopkins university, Washington, D.C., page no.25. URL:
http://www.protectionproject.org/wp-content/uploads/2010/11/CP-Model-Law_Jan-2013_Final-w-
cover.pdf

Reducing Maternal Mortality 43

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