Through my work for UNICEF in Indonesia, I met a lot of midwives, mothers and babies and I heard a lot of stories, some sad, some happy and some very inspiring. As today is International Midwives Day, I thought I’d include some of those stories from a trip I made to East Sumba a few years ago.
Sumba is an island in Eastern Indonesia. It’s fairly hard to get to, very poor and very isolated. Many of the villages are cut off from quality roads, which means not only can they be hard to reach, but clinics and services are often difficult to travel to.
A Trained Midwife Makes All the Difference
- Mothers and babies waiting at Pustu Patawang
Ibu Nonce is the main midwife at Pustu Patawang, a subsidiary health clinic to the local health centre in East Sumba. Her clinic looks after four rural hamlets that are spread over quite a wide area. The furthest hamlets are not connected to the clinic by good quality roads, so pregnant patients often prefer to walk several kilometres to reach the clinic. When women go into labour, Ibu Nonce also has to walk long distances to reach them, so knowing how to deal with problems swiftly is vital. Ibu Nonce received training last year and is extremely happy with what she learnt. “Before, I didn’t always know what to do, or how to recognise signs of danger in pregnancy.”
One of her patients, Ibu Karolina, who lives in one of the furthest hamlets, developed pre-eclampsia in 2003. Her house is four kilometres away from the clinic, and because the roads nearby are either bad quality or non-existent, when she went into labour, she gave birth at home.
Before the training, Ibu Nonce didn’t know how to recognise early signs of pre-eclampsia and so had no idea that Karolina was suffering from it, and wasn’t prepared. “Karolina’s house is not particularly close to the main road, so when it became clear that she would have to be taken to the health centre, four of her neighbours had to carry her 200m to a vehicle, on a piece of cloth.” From there, the minibus drove her nearly 20km to the health centre, and once there they were able to treat her.
Karolina was lucky to survive; pre-eclampsia is one of the main causes of maternal death in Indonesia. If left untreated it affects the brain, leading to headaches and blurred vision followed by convulsions and coma. So recognising it early and making adequate preparations is essential for saving lives.
- Baby being weighed at Pustu Patawang clinic
Ibu Alfia came to see Ibu Nonce for a check up in the first two to three months of carrying her third child, but didn’t come back again until she was six months pregnant. She’d seen her midwife during her first pregnancy and had no problems, so after a good result from her first check up, she didn’t expect there to be any problems the second time round.
But when Ibu Nonce saw her, she realised straight away that she had become anaemic, the insides of her eyes were white and her skin was pale. If left untreated, anaemia can cause poor foetal growth and low birth weight in babies, and lead to urgent life threatening blood transfusions in pregnant women.
Ibu Alfia’s pregnancy was already quite advanced so she was at a high risk of suffering severe complications. Because of Ibu Nonce’s training, she now knew how urgent it was that Ibu Alfia received proper treatment, and wasted no time in sending her to the nearest hospital. She needed to have two blood transfusions, and had to stay in the hospital for a couple of weeks until she was better. Thankfully both Ibu Alfia and her baby came through the pregnancy with a clean bill of health but if Ibu Nonce hadn’t known how important it was to send her for emergency help, the situation may have been much worse.
Ibu Nonce is very happy that she can now see these vital signs early on and prevent more pregnancies developing serious complications. In Patawang, the hills and lack of quality roads mean that pregnant women face more risks than usual, so her new knowledge is essential for keeping them safe.
- Ibu Alfia (left) and Ibu Karolina wait to see Ibu Nonce
Better skills are vital, but the community needs to understand too
Despite her increased skills and good facilities, Ibu Merpati Wali - another local midwife, is fighting against a culture of home deliveries, assisted by experienced but unskilled family members and neighbours. She is examining more and more pregnant women, but being new to the area, her clinic has only been running for one year so far. In that time she’s delivered just three babies there, with most parents still choosing to give birth at home, some still without her help.
The culture in Sumba is very hierarchical, with older family members, and men having much more input than younger women, even when it comes to giving birth. One of the difficulties faced by midwives like Merpati Wali, is getting the community to understand, as well as changing the opinions of their pregnant patients.
One of Ibu Merpati Wali’s regular patients was pregnant with her fourth child and in a high risk category because of her age (36). Her previous three children had been born with no problems, and the fourth pregnancy was also very healthy. But a week before she gave birth, she told Ibu Merpati Wali that she wouldn’t be calling for her when she went into labour. Her first two pregnancies had been assisted by a midwife, and had gone by without a problem, so despite having no training, her husband had delivered the third child. Again this was fine and so he believed that he should deliver their fourth child. This was against the mothers’ wishes, but she was a little scared of her husband as he was very strict and could even be violent at times. He worked long hours selling produce at the market and usually didn’t get home until late, so had never been to any of the consultations with the midwife. She tried to meet with him to explain the dangers that his wife would face if he insisted but there just wasn’t the opportunity due to his working hours.
One day in April 2008, Merpati Wali got a phonecall from the husband asking her to come quickly, but by the time she arrived, the baby wasn’t breathing. “He was so sure that he could deliver the child himself but had no idea what to do when things started to go wrong” she says sadly. This child’s death should have been easily preventable. He had become stuck in the birth canal and according to the autopsy, probably died of asphyxiation due to his shoulders being stuck. “He was a big baby and the father didn’t have enough experience to be able to deal with the situation.” Sadly if Ibu Merpati Wali had been called in time, she could have prevented his death. “When I arrived at the house, the father was beside himself. He knew it was his fault but by then it was too late.”
Since then the mother has been to visit Ibu Merpati Wali four times to apologize for not calling her sooner. “She’s suffering from stress and trauma and so is the father but he’s too ashamed to come.”
Merpati Wali wants to be able to prevent this from happening again by spreading information throughout the village. Although she is trusted and known by the women, when their families don’t understand the situation, there’s little she can do. But she is hopeful for the future, “If we can socialize enough, then we can save more lives.”
A trained midwife makes a huge difference
- Ibu Alfi sits in her front room with two of her children: Natalia (5) and Tania (2)
Even in the more established areas, such as Pustu Patawang, it takes time to get families to understand. Ibu Alfi lives in a small village near to this health clinic and often went to see her midwife for check-ups. She had already given birth to two children with the help of a traditional birth attendant, known as a dukun, but with her third pregnancy, she really wanted to use the local midwife. “There were no problems when I gave birth to my first two children, but this time, something just seemed wrong.” She knew that her local midwife was trained and could give proper medicine, but the dukun would only really be able to give her pregnancy massage. Her parents didn’t agree with her though, they’d always used the dukun before and never had any problems, and besides, her other two children were healthy. They didn’t see the need for a midwife when the dukun was obviously capable of delivering children.
Alfi and her family live a long way from town so to earn money, her husband often has to stay away for a night or two at a time. He was away the night that she went into labour, but as her parents were with her they called for the dukun. Because Alfi insisted, they tried to ring the midwife too, but she couldn’t be reached on her phone. If her husband had been there, he would have gone round to the midwife’s house himself, but it wasn’t a priority for her parents. Alfi had to deliver her baby with help from just the dukun, but all the time she hoped someone would arrive by motorbike so that they could be sent to fetch the midwife.
Several hours later, the baby was born healthy, but immediately after giving birth, Alfi started to haemorrhage. “Blood was gushing out of me, but the dukun said she couldn’t help, she didn’t know what to do. And then I passed out, with the blood still flowing.”
By this point, with the dukun as well as Alfi’s parents starting to panic, the midwife had been located and was on her way. She arrived not long after Alfi passed out and because of her training, she knew exactly what to do. She immediately gave her an injection, and within half an hour, Alfi had regained consciousness and had stopped bleeding. The midwife made sure that she was looked after continually for the next few hours until arrangements could be made for her to travel to the nearest hospital for a full check-up.
“I’ll never use a dukun again” says Alfi, “and now my parents absolutely agree.”
- Tania, Natalia and their friends are happy they have a new sister to play with
Around 140 families live and work here, building temporary homes nearby and collecting recyclables to sell to the government traders who weigh and pack them up onsite.
Gaudencio Cruz moved to Tultitlán several years ago to work on the rubbish dump but now works as the Tultitlán community centre coordinator. He says that there are all sorts of issues here, but one thing that’s really important is working with families to encourage them to want to give their children an education. Public schools are theoretically free but children still need to buy books, clothes and pay for transport, which all adds up and as many of the parents can’t read or write, they don’t see why their children would need to either.
They also work with the government so that all students can take tests and receive diplomas to prove that they’ve passed and to enable them to sign up to the public school when they’re ready.Gaudencio and his staff work with the community to identify kids who are not at school, invite them to come along, and most importantly, encourage them to keep coming back.
The community centre is managed by Amextra, an NGO that works throughout Mexico, using their motto ‘change your way of thinking to change your way of life’ as a driving force. They believe strongly in empowering communities to take charge of their own futures and encourage locals like Gaudencio to take on staff roles.
But they also emphasise the importance of understanding why people do things a certain way because only then can things change. This is communication for development working at its best – Amextra provides support and training but it’s the community that decides what they need.
It’s not just about education though; Amextra’s staff encourage the community to make the most of what they have in many other ways too: They run various courses from nutritious cooking to how to set up and manage a business;
The school has eco-toilets – not only have they been constructed from recycled materials but they will eventually provide a free source of compost; and the pre-school mothers and babies class encourages parents to save their scrap waste so that the children can use it for crafts projects.
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