Maternal Mortality in Indonesia

Maternal mortality is increasing, especially in Southern Asia and Sub-Saharan Africa. The ethnography “Dying Mother: Maternal Mortality in Rural Indonesia” written by M. Cameron Han follows the study of maternal mortality in Lombok, Indonesia and shares the stories of two maternal deaths that Han witnessed while living there. She successfully explains how maternal mortality is not just caused by the lack of availability of services and knowledge, but also by a community’s culture and beliefs. A comparison of how the World Health Organization and a medical anthropology views maternal mortality will be explained throughout this essay. Maternal mortality cannot be solved with just money and resources, but rather through a thorough understanding of a community’s cultural roots.

According to the World Health Organization, Maternal mortality is ‘the death of a woman while pregnant or within 42 days of termination of pregnancy or from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes’ (Global Health Watch). Maternal mortality is caused by direct or pre-existent medical problems that disturbed the pregnancy, systems and laws that affect the availability, accessibility and quantity of services, and underlying socio-legal conditions (Global Health Watch).

From a medical anthropological perspective maternal mortality is caused by so much more than the accessibility, quantity and quality of services available to communities. A community’s cultures, perceptions, methods of treatment, and ethics have a strong role in the outcome of maternal mortality. Wealth, knowledge and resource availability must work together with addressing community’s fears and cultural views of hospitals and new birthing techniques in order to successfully reduce, or ultimately eliminate maternal mortality whether it is in Lombok, Indonesia, or around the world.

The Medical anthropological article “Dying Mothers: Maternal Mortality in Rural Indonesia”, shares the stories of two maternal deaths she witnessed during her twenty month stay from 1993 to 1995 in Lombok, Indonesia. Both of the deaths occurred to Sasak women in the hamlet of Pelocok (Han). There are about 800 Sasak peasants in Pelocok (Han). The majority of Sasak people are poor and malnourished because of the lack of nourishing food, small amounts of land, and the frequent droughts and monsoons that ruin the crops that they do possess (Han). The average annual income per household is about 200,000 Rp, which is equivalent to $91 US Dollars (Han). This income is not enough to support the minimal needs of the Sasak people.

The first maternal death that Han witnessed took place in 1994 by a middle-aged woman named Inaq Hin. She was pregnant with her eighth child and was planning on having her child in her house. There were no clinics or hospitals nearby, and even if Inaq Hin wanted to go to a clinic or hospital, she did not have enough money for transportation or to pay the hospital bills after the birth (Han). Inaq Hin gave birth to a son but the placenta was unable to be removed for several hours. Papuq Isa, the traditional birth attendant that aided Inaq Hin during the birth, tried several traditional techniques such as massaging the stomach, in attempt to remove the placenta (Han). Inaq Hin died shortly after her birth due to the inability for the placenta to be removed and because of the large amount of blood that she lost during this process.

After Inaq Hin passed away, the other Sasak women shared with Han how they believe she died because it was ultimately her fate. Papuq Isa, the birth attendant, as well as the rest of Inaq Hin’s family and friends believe that they did all they could but it was simply what “Allah” wanted (Han). Her son was still alive after she died but he was neglected because everyone believed his fate was also to die and be with his mother. Han was aware of the weak newborn and insisted that he be taken to a clinic to be taken care of, but his grandmother was resistant and stated that “it was in God’s hands” (Han). Inaq Hin’s son died two weeks after his birth because of the lack of care and attention he received by his family. Similar to the death of his mother, everyone believe that is what God intended to happen, for it was his fate.

The second death that Han witnessed in Pelocok took place just a year after the death of Inaq Hin. Since the previous year, a new childbirth post had been open fairly close to the Pelocok. Inaq Marni was in her mid-forties and was pregnant with her eleventh child. She was strictly told that it was necessary for her to give birth in the clinic because she had a critical case (Han). She was strongly against the idea of giving birth in a clinic and decided she would stay home with her traditional birth attendant, Inaq Hapim (Han). After going through a long and painful labor, Inaq Marni finally gave birth, but to a dead child. Han discovered that Inaq Marni’s situation was much more critical than she was aware of because Inaq Marni was actually pregnant with twins. Inaq Marni was then taken to the birth clinic where another caregiver, Rini, helped deliver another still-born child, more than twelve hours after giving birth to the first child. Similar to Inaq Hin, the placenta was unable to be removed, thus leading the unfortunate death of Inaq Marni.

Unlike during Inaq Hin’s death, the traditional birth attendant, Inaq Hapim and the caregiver at the birth clinic, Rini, were blamed for her death (Han). Inaq Hapim and Rini were blamed for her death because their birthing methods not successful and neither thought to try basic birthing techniques, such as the gebuk in which a “strip of cloth [is] tied above the stomach during labor to encourage the baby and placenta to go down and out of the body” (Han). Whether it was the lack of knowledge or just the specific situation that caused Inaq Hapim and Rini to fail in attempting various other techniques during the birthing process, it ultimately caused the death of another mother in Pelocok.

The World Health Organization views maternal mortality as a health problem that is caused by very surface issues that can be resolved through new medicines and implementing new health laws and policies, which take both money and power to do. From a medical anthropology perspective deeper issues of communities must be acknowledged to truly work to end maternal mortality. For example, in the Pelocok community the belief in fate and what “Allah” has planned is very strong. After the death of Inaq Hin, the community did not think to blame Papuq Isa, the traditional birth attendant, and her birthing techniques. Whether it was Papuq Isa’s birthing techniques, or the lack thereof that caused the death of Inaq Hin, the Pelocok will never truly understand or accept, because of their strong religious beliefs. The lack of current medical facilities is not viewed as a real issue to the Pelocok community because if someone is meant to die than that is what will happen, an opening of a new clinic or hospital will not change the fate of an individual in their eyes.

Fear of the unknown is another factor that increase maternal mortality. The story of Inaq Marni is an example of how fear restricted her from having a healthy, successful birthing process.  Inaq Marni was strongly against giving birth in a clinic or hospital because hospitals are viewed very negatively in their community. Hospitals are viewed as a place where people die, so many avoid going there in fear. Inaq Marni even stated “why go somewhere for to die?” (Han). To the Pelocok community, death is tied directly to an individual’s fate, so to them going to a hospital or clinic is like sealing your fate of death.

            Culture is a medical anthropology concept that applies to the issue of maternal mortality in Lombok, Indonesia.  Culture is always evolving and is something that both individuals and groups of people experience. Culture gives meaning to what individuals feel, do and think (Ceron). The culture of the Sasak women played a part in the two maternal deaths that took place because the women’s beliefs, methods, and understandings of the situation are all developed from their culture. The women’s strong belief in fate and “Allah” is a part of their culture.  In comparison to the Western society, doctors and nurses try as many techniques and procedures as possible to have a successful birthing process. They try all methods possible before coming to the point of acceptance that nothing else can be done to improve a situation. In both cases with Inaq Hin and Inaq Marni, I don’t believe that the traditional birth attendants really did all they could to prevent the deaths of either of the women. The birth attendants only tried a few methods to help save the lives of these women but finally accepted that it must be their fates to die. This may be viewed as the birth attendants giving up, but rather this is their culture, accepting what they believe is an individual’s fate and letting “Allah’s” plan unravel.

            The Pelocok’s social representations and perceptions are also other medical anthropology concepts that cause maternal mortality. In the Western society it is thought of as normal to go to a hospital to give birth, to be treated by professional doctors and nurses. Giving birth in medical hospitals and clinics usually costs a substantial amount of money. This is an aspect that restrains the Sasak community from going to medical hospitals and clinics. Many Sasak women who give birth in hospitals are indebted because they are unable to pay for the bills with the amount of income they earn. For this reason, hospitals and clinics are represented as too costly and unnecessary to deliver a child. The perception that hospitals and clinics represent death, also hold back the Pelocok community from going there to deliver children, or receive any medical help at all.  If more hospitals and clinics were built near Pelocok, that does not necessarily mean that there more people will go to get medical treatment or there will be less maternal deaths because the community already perceives hospitals and clinics as negative and inaccessible.   

            After applying medical anthropology concepts to analyze maternal mortality, I have come to the realization that as much as we would like to solve all global health problems, there is just so much more to solving this issue than through the use of wealth and improving accessibility to communities. To truly solve global health issues, community’s culture and beliefs must be understood. There are so many various different cultures and beliefs around the world, it will take a lot of time and understanding to truly see the different perceptions that communities all over the world have. For example, the differences between the birthing process in Western society and in Pelocok are drastically different. In the Western society hospitals and clinics are viewed as a safe and almost comforting place to deliver a child. In comparison, the women in Pelocok have a large fear of hospitals because they believe it is the place to die, therefore they avoid going to the hospital to receive medical help as much as possible.

            From a practical perspective, the World Health Organization’s view of maternal mortality and what can be done to solve the issue must be slightly altered. Understanding different cultures is a very important aspect in effort to end maternal mortality in the world. The World Health Organization is approaching this global health issue as something that can be solved with money and power, but it really takes much more than that.  Money and power do help work to solve the issue of maternal mortality but are not the sole solutions. Medical anthropological studies similar to the one study M. Cameron Han made in Lombok, Indonesia will help organizations have a better understanding of communities and their cultures. Once you truly understand a community’s culture, working to solve health issues will be easier because you understand the people’s views and beliefs. Understanding a community’s culture, views, and beliefs is very important because you will be able to understand their points of view and identify what exact areas communities need to be more educated and supported.

            Maternal mortality is an issue that the world will continue to face until community’s cultures, beliefs, and perceptions are thoroughly understood. You cannot solve this health issue by just providing services and resources for the people. You really have to take the time to understand a community to help end and prevent maternal mortality in the world. M. Cameron Han’s study of maternal mortality Lombok, Indonesia is a clear example of how both surface and deep issues in a community must be addressed to successfully put an end to maternal mortality.

Citation

Ceron, Alejandro. “ Untitled Lecture, A 215.” Lecture, University of Washington, Seattle, WA, October 22, 2012.

 Hay, M. Cameron. "Dying Mothers: Maternal Mortality in Rural Indonesia." Medical Anthropology: Cross-Cultural Studies in Health and Illness 18.3 (1999): 243-79. Taylor & Francis Online. Web. 11 Dec. 2012.

"Maternal Mortality: Need for a Broad Framework of Intervention." Global Health Watch 3: An Alternative World Health Report. N.p.: Zed, 2011. 124-32. Web. 11 Dec. 2012.