Sudir Small

Sudirman Nasir, 17 July 2014

This article first appeared in the Jakarta Globe on the 3 July 2014.

Amid the fierce presidential campaigning, not many people think and talk about the figure and the role of our next first lady. Sure, presidential hopeful Prabowo Subianto is currently unmarried but that may change and it is true that any first lady has no formal role in our government. But informally, as shown in several countries, first ladies can play important roles and contribute significantly to the people’s welfare.

Khofifah Indar Parawansa, the former women’s empowerment minister, a prominent figure within the Muslimat Nahdlatul Ulama — the women’s section of the country’s biggest Islamic organization — and spokeswomen for the Joko Widodo-Jusuf Kalla campaign, has put the crucial role of our next first lady on the agenda. According to Khofifah, who undoubtedly is eying a role for Joko’s wife Iriana, the first lady may perform a unique role in supporting village volunteer activity that is not part of any formal government policy.

Tackling maternal mortality

Programs such as the Posyandu (village health outreach) and PKK (family welfare and empowerment) play crucial roles in promoting maternal health campaigns, for instance by encouraging expectant mothers to seek antenatal care (routine checks needed during pregnancy) and give birth in a proper health facility. These activities are important to reduce the risk of maternal death.

Maternal mortality is an important public health issue in Indonesia. Our maternal mortality rate currently stands at 359 deaths per 100,000 live births. This rate is among the highest in Southeast Asia. Our progress in achieving the Millennium Development Goals target of a maternal mortality rate of 102 per 100,000 live births by 2015 remains a big challenge.

Many studies have pointed to biomedical issues contributing to the high number of maternal deaths, such as post-delivery bleeding, infection, high blood pressure and obstructed labor. These are often exacerbated by the poor quality of emergency obstetric services, poorly organized referral systems and inadequate human resource distribution, particularly in rural areas.

However, besides these biomedical and health system factors, there are several studies, including one in which I am currently involved in, in sixteen villages in Southwest Sumba (East Nusa Tenggara) and Cianjur (West Java), that have found various non-biomedical factors that also contribute to the high number of maternal deaths in the country.

It is noteworthy that most maternal deaths occur among mothers who give birth at home, unassisted by a skilled birth attendant. Though there is an increase in women who deliver in health facilities, the rate is not as high as it should be. Our current study revealed that there are numerous social and economic barriers that may prevent pregnant women from giving birth at a health facility, even though in the last few years the government has provided insurance that covers costs for such services.

The remaining barriers include distance, poor road conditions, lack of availability of transportation (including the cost of transportation) and indirect costs e.g. the cost of accommodation and food for family members who accompany the expectant mother. Furthermore, there are some factors related specifically to maternal health services, such as limited availability of a village midwife — because of many midwives do not reside their assigned village for a variety of reasons — or difficulties in contacting the midwife.

Our study also shows that poor perception of the benefits of delivery at a health facility, preference for home delivery and a preference for assistance of a traditional birth attendant (TBA) as well as limited communication and referral of pregnant mothers from TBA to midwife are also important barriers. Many women prefer to utilize TBA services because of the physical closeness of the TBA, but also because of the psychological and cultural support provided by them.

Enthusiasm and performance

Importantly, however, we found that some villages performed a lot better than others in terms of maternal health indicators such as higher attendance at antenatal care sessions and higher levels of delivery at health facilities. It turns out that better performance and enthusiasm of village midwives and volunteers like those of the Posyandu program is crucial in achieving better results. The study also suggests that these midwives and volunteers perform better and are more enthusiastic because they receive support from important stakeholders, such as the village head or the wife of the village head.

It is not hard to imagine that the enthusiasm and performance of all of these village midwives, village volunteers, village heads and wives of village heads will get a boost if our first lady — or the next president, for that matter — demonstrates a leading role in tackling this important public health issue. Moral and political support can make a big difference. Moreover, the first lady can set an important example for the spouses of leaders at all levels, like governors and district heads.

It is noteworthy that in other countries, the unique role of the first lady has long been visible. In the United States, for example, several first ladies played important roles in supporting strategic issues. Lady Bird Johnson pioneered environmental protection; Pat Nixon encouraged volunteerism; Betty Ford supported women’s rights; Rosalynn Carter promoted awareness of mental health issues; Nancy Reagan founded the “Just Say No” drug awareness campaign; Barbara Bush promoted literacy; Hillary Clinton sought to reform the US health care system; and Laura Bush supported women’s rights groups and encouraged childhood literacy. The current first lady in the US, Michelle Obama, has become identified with supporting military families and tackling childhood obesity

Indonesia’s next first lady could become a passionate advocate for maternal health — village-level health workers and volunteers will surely appreciate the support.

Sudirman Nasir is a lecturer at the Faculty of Public Health at Hasanuddin University in Makassar and a senior research fellow in the EU-funded ReachOut Project at the Eijkman Institute in Jakarta.

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