Michael Victor Sianipar – Indonesia may be progressing slowly and steadily toward fulfilling its targets under the Millennium Development Goals, but the issue of maternal health continues to present many challenges.
Government statistics show that the maternal mortality rate declined from 308 per 100,000 live births in 2007 to 228 per 100,000 in 2010. Under the MDGs, the country must bring that figure down to 102 deaths per 100,000 live births by 2015.
But a report last week by health officials in Bali has highlighted a worrying reversal, with the provincial maternal mortality rate increasing from 58 per 100,000 in 2010 to 84 last year.
Nyoman Sutedja, the head of the Bali Health Office, attributed the increase to the lack of quality health care available at community health centers (Puskesmas).
Slamet Riyadi Yuwono, the Health Ministry's director general for nutrition and child and maternal health, acknowledged that maternal mortality rates might be on the rise in some regions but cautioned against reading too much into the figures.
He said the rise could be attributed to the government's 2010 policy to provide free maternal and child delivery services.
"Many people used to give birth at home because they were afraid and uninformed," Slamet said.
"Today, more are willing to use the service provided by the government for free. The mortality rate has increased because what used to be unaccounted deaths at home are now recorded in our health centers as more mothers rely on these services.
"Indeed, the absolute number as recorded has increased, but the real rate has gone down."
Slamet said health workers failed to provide timely assistance to mothers for several reasons: reluctance by some women to report their pregnancies early, lack of transportation forcing women to give birth at home without proper medical equipment or drugs, and limited medical facilities and personnel.
The principles of regional autonomy also pose a challenge to the Ministry's ability to oversee local health services, he said.
"The ministry can only provide technical support and devise standard operating procedures for local medical practitioners, but administrative powers lie with the local government," he said. "We have no power to punish or sack individual midwives and doctors.
"However, the government has instructed governors to advise district heads on health issues."
Transportation is a key element in tackling maternal mortality, said Zaenal Abidin, the secretary general of the Indonesian Doctors Association (IDI).
"Indonesia is an archipelagic state. It is important to have medical boats that can act like an ambulance to deliver pregnant mothers to another island that has the necessary medical facilities," he said. "The boats should be equipped with complete facilities, including antibiotics, IVs and oxygen concentrators."
He said local customs also had the potential to do harm. In East Nusa Tenggara, for instance, newborn babies and mothers are traditionally required to stay in a closed room with a wood fire burning for up to six weeks.
Zaenal stressed that health workers must educate local communities about the dangers of some rituals and traditions that put the health of both the mother and the baby at risk.
"Doctors sent to the provinces receive pre-departure training that teaches them about the local traditions that they will be working with," he said. "They should also prepare themselves by reading or asking their seniors who've been there for advice."
He also noted the need to be aware of local sensitivities. "There are good and bad cultural practices," he said. "We wish to keep the former and change the latter. But we cannot confront the public outright, as that will only lead to resistance."
[Additional reporting by Made Arya Kencana.]