It was a rainy day in the remote village of Boti in the mountains of South Central Timor. Mesriana covered her head with a banana leaf as she left her home to take some corn and beans from the grass thatch granary hut behind her home. She was preparing lunch for her husband, Mikael and their two children who were busy feeding their livestock – a couple of saddleback-breed pigs. After taking the ingredients she boiled some corn. Mesriana had to eat well, as she was expecting her third child within weeks.
Just like most other days in rural Boti, Mesriana ate lunch with her family. However, after lunch Mesriana suddenly began to feel a sharp pain in her stomach. Her third child was coming. With no car or motorcycle, Mesriana and her husband had no choice but to begin the six-kilometre walk to the sub-district health clinic. Throughout the two-hour journey, Mesriana’s stomach obstructed her view of the path beneath her feet. Mild pain also continued to hinder her, reminding her that the baby would come soon regardless of whether she could reach her destination or not. Finally, Mesriana was able to reach the health clinic and gave birth safely.
Challenges delivering maternal and neonatal services
Indonesia has one of the highest maternal mortality rates in Southeast Asia. Yet within Indonesia there are a number of clear disparities and widening development gaps. Data shows correlations between disadvantaged socio-economic and health outcomes and distance, or geographic remoteness from core parts of Indonesia, including Java. The neonatal mortality rate in NTT is one of the highest in the country at 31 deaths per 1000 births. The national average for maternal mortality in Indonesia is 228 women for every 100,000 live births.
Research by the Australia-Indonesia Partnership for Neonatal Health has found that in poor provinces in Eastern Indonesia, the rates are worse, at 306 per 100,000 live births. Along with four of the other eastern provinces in Indonesia, NTT sits at the bottom of the Human Development Index (HDI) - 31st out of 33 provinces. Further, whilst NTT has a relatively small population of approximately 4.9 million, this is rapidly growing at an annual rate of 2.07 per cent, much higher than the national average of 1.49 per cent.
Findings from a UNICEF review into maternal and neonatal health conditions in Indonesia showed that in seven provinces in Eastern Indonesia, one in three births take place without assistance from a midwife, nurse or doctor. The review also found that the average maternal and neonatal mortality rates in peripheral provinces were much higher than mortality rates in core provinces within Java.
Climate vulnerability and lack of infrastructure
In many villages in rural and remote districts such as South Central Timor, vulnerability to extreme climate and environmental conditions is a key obstacle for maternal and neonatal health. Back in Boti village, another expectant mother, Yovanche, is also concerned about the distance from her home to the health clinic. Visiting the health clinic for antenatal health checks is common practice in preparing for safe childbirth, but these services are not always accessible for some in remote parts of the village. ‘We have to go to the health clinic every month’ Yovanche explained, but ‘usually it is difficult to get there because it is far.’ These conditions are only worsened by the steep hills and dirt paths which quickly turn into mud in the rainy season. ‘In the dry season we can use a motorbike taxi because the road is accessible… but if there is rain we cannot use the motorbike taxi, so we must walk’.
The local government is aware of these problems. Dr Husiani, head of the district health department of South Central Timor, shared her experiences of these challenging obstacles for expectant mothers hoping to access health facilities. The problem also exists for health providers who try to visit remote villages. ‘The geography of South Central Timor is made up of hills, mountains and wide rivers. In the wet season there is a strong current in the river. There are no bridges. This sometimes makes it difficult for communities to cross these wide rivers’, explained Dr Husiani.
Without basic infrastructure such as bridges and roads to the most remote villages, expectant mothers like Mesriana and Yovanche, may not be able to reach health services in time. In many of these villages, local communities have taken a number of measures to help bring pregnant mothers to the health clinic. Head of Sopo village, Mathias, said that there are moments when roads are inaccessible and vehicles have been prioritised for others. Yet getting to the hospital remains crucial, ‘so we work together’, explained Mathias. ‘We carry the mother on a stretcher; we make a chair, then we tie it to timber, we have the mother sit on top, then two people carry her.’
One of these emergency measures involves a team taking turns to carry the pregnant woman until they arrive at the health clinic. Health workers from Niki-Niki in South Central Timor also share stories of similar situations. Delda, a midwife coordinator, shares her experience of a time when the health clinic team attempted to reach a village but the road was in poor condition and the ambulance could not enter. ‘By working together, the village community made a stretcher to help the patient. They made the stretcher out of bamboo.’ Such stories demonstrate the resilience and resourcefulness of these village communities. But such improvised practices are also time consuming and impractical.
Collective action and inventive stretchers alone have not curbed maternal and neonatal mortality rates. Speaking about his experience, Dr Suryo of South Central Timor explained the challenges. ‘With road conditions as difficult as this, it can become hard for us to deliver optimal service to the community.’ Dr Suryo described one case involving a pregnant patient whose condition meant she could not give birth in the village health clinic. Dr Suryo and a team from the village were mobilised to bring the patient to the hospital as soon as possible. However, on that day the road conditions were difficult, compounded by rain and floods in the surrounding rivers. The group was forced to wait until they could cross the river, with tragic consequences. ‘When helping this pregnant mother (and her baby) we tried the best we could but we could not save them both...’ Dr Suryo explained.
I choose the ‘rumah tunggu’
One of the first steps taken by local government and local communities to reduce the maternal and neonatal mortality rates in rural and isolated areas has been the establishment of the rumah tunggu bersalin (maternity lodge). These rumah tunggu allow expectant mothers to stay closer to the health clinics as they near their expected dates for childbirth. Traveling such a long distance while in labour is a real concern for Anita, one of the women using the rumah tunggu.
‘What if during the middle of the journey the baby wants to come out?’ Anita asked. ‘I chose the rumah tunggu…In my opinion, it is better to be in the lodge because it is closer to the health clinic than home is.’ Facilities provided at the lodge include water, bedding, electricity, a kitchen and food. ‘Just like my own home’ Anita added.
The lodge is just one of the steps being taken by local communities, government and civil society actors as part of a partnership within the Revolusi Kesehatan Ibu dan Anak (Maternal and Pediatric Health Revolution). Since 2010, this partnership has been part of the long-term structural effort to reduce maternal and neonatal mortality rates in NTT province.
Development gaps and challenges
The stories of Mesriana, Anita and others illustrate the level of climate vulnerability and risk faced by rural and remote communities situated far from health facilities and medical practitioners. Their stories highlight ongoing disadvantages and development gaps in areas such as maternal and neonatal health for communities in peripheral provinces like NTT, far from the urban centres of Indonesia. While the rumah tunggu can provide a useful local solution, it cannot redress the roots of larger issues related to urban-rural and core-periphery development gaps. These disparities are complex and deeply rooted in the history and governance structures of Indonesia.
Nicholas Metherall (firstname.lastname@example.org) co-produced the documentary film Lanan Mafatu during an internship with the Australia Indonesia Partnership for Maternal and Neonatal Health (AIPMNH). Nicholas completed his honours through joint cooperation between La Trobe University, the University of Nusa Cendana and Cenderawasih University.
His Twitter account is: @NMetherall.