Maternal and Neonatal Health in NUSA TENGARRA TIMUR (NTT), INDONESIA.

Maternal and Neonatal Health in NUSA TENGARRA TIMUR (NTT), INDONESIA.

The area of Indonesia known as NTT is one of the most under resourced in Indonesia. This is partly because of the dry mountainous terrain and remote villages. The roads are winding, have poor surfaces, and many pot holes make slow going, as in our visit to a clinic, below.

The National Census data shows the NTT has amongst the worse health in Indonesia with malaria and tuberculosis having high prevalence. These two conditions alone can be life threatening and cause death in pregnant women or their babies. Poverty and poor nutrition cause much anaemia which is a catalyst for haemorrhage in childbirth.

Housing is poor and facilities almost nonexistent. Water must be carted in containers to the home. Basic hygiene is a major issue because of the lack of water. Sepsis is shown to be 6% of all deaths under 5 years of age.
A small child is seen below, carting 2 containers of water from the local trickling river.

There are a disturbing  number of maternal and neonatal deaths in this area. A major cause of death is haemorrhage and eclampsia. Both which require early follow up. The WHO advises that mothers and children continue to die due to delays in

  • seeking appropriate care,
  • reaching a health facility and
  • receiving appropriate management at the facility.

 

FOHG is training midwives to arrange potential transport in case of emergency care, and refer women early to facilities instead of trying to manage problems themselves. FOHG also train staff within the larger hospitals to manage such emergencies.  In Australia, all women have ultrasounds early in pregnancy. With gifts of machines from NGO’s, recently volunteer ultra sonographers ‘up skilled’ staff in the use of ultrasound to detect problems earlier, thus saving both mother and babies lives.

Poor access to facilities has been a particular problem in the area around SoE. SoE is towards the central highlands of West Timor and many hours from the capital Kupang. The roads are narrow and few private people have cars. Most people travel on public transport, which means the back of trucks or overfilled busses.  Not the type of vehicle a woman experiencing labour can use. Even the price of such transport can be prohibitive for families.

It is the families that have the last word on whether a woman can be transported to a facility for delivery.  A refusal to allow women to travel may be the cost of travel or cultural reasons.  Over 85% of births are facilitated by midwives in the NTT.[1]  Although the Government of Indonesia discourages it, people are familiar with women delivering at home, not in hospitals.  Hospitals are for sick people. The  use of health facilities by pregnant women is less that those at home. The 2018 census  information (Indonesian Ministry of Health, Health Research and Development [RISKESDAS}) shows that most births are still taking place at home (16%)  which is almost the same rate as the use of health facilities (18%).

Their trust in the local midwife, or even the ‘traditional’ midwife (dukan) remains very strong. Sadly, the midwives are often young, often unmarried, and have only a basic education. They have few resources at their disposal, (eg., syntometrine used routinely to prevent bleeding, is not available) and the traditional midwives have only their experience and beliefs to support them.  Regardless, many people trust the local dukan implicitly, often to their detriment.

Maternal and neonatal deaths in the SoE area are very high. Dr. Lorens, the coordinator of ‘Maternal and Neonatal Auditing’ in West Timor, reports that the total number of maternal deaths in SoE for twelve months to August 2018 was 30 (We do not have the total number of live births). The main causes reported were haemorrhage and eclampsia. The maternal deaths in other NTT regions, where FOHG also work are Ende 8 and Nagakeo 2. Neonatal deaths in Nagakeo alone were 30.  Major causes of neonatal death (amongst others not recorded) include asphyxia (11), congenital abnormality (6) and pneumonia (4). A major cause of perinatal death is low birthweight. Much of this is due to poverty and resultant poor nutrition of women in NTT.

To put these figures into some context, Australia has 3.5 maternal deaths for every 100,000 births [2] and 9.7 neonatal deaths per 1000 births. Of these only 2.1 were neonatal deaths, the rest were stillbirths[3] (AIHW 2018).

[1] RISKESDAS Health of Indonesia from National 2018 census  information

[2] Australian Government. Australian Institute of Health and Welfare (AIHW): Maternal Deaths in Australia 2012 -2104

[3] Australian Institute of Health and Welfare (AIHW) 2017, Perinatal deaths in Australia 2013–2014. (Released 29 May 2018)

Australian perinatal mortality by state.

Figures for the health of Indonesia nationally can be found on the WHO website. However, according to the Indonesia’s Health Research unit (RISKESDAS)[1], Nusa Tenggara Timur (NTT) as a Province has poorer health  than the national figure at 306 maternal deaths per 100,000 live births. Neonatal mortality is 57 neonatal deaths per 1,000 live births.[2]

To try and combat such deaths Flinders Overseas Health Group has supported the opening of the Muder Ignancia Hospital where the staff are being encouraged to upskill and take special care of mothers and babies.

[1] GOI, RISKESDAS Health of Indonesia from National 2018 census  information

[2] GOI, RISKESDAS Health of Indonesia from National 2018 census  information

[1] Australian Government. Australian Institute of Health and Welfare (AIHW): Maternal Deaths in Australia 2012 -2104

[1] Australian Institute of Health and Welfare (AIHW) 2017, Perinatal deaths in Australia 2013–2014. (Released 29 May 2018)

[1] GOI, RISKESDAS Health of Indonesia from National 2018 census  information

[1] GOI, RISKESDAS Health of Indonesia from National 2018 census  information

The opening was very traditional. The Heads of the village are seen here dressed traditionally as part of the opening ceremony.

The FOHG maternal and neonatal team volunteers each had a tree planted in the grounds of the new facility, along with their names.

The midwives working in SoE have trained at the Kupang Polytek. FOHG Maternal and neonatal team also provide seminars to upskill the midwifery trainers at this Polytek. These up to date teaching and skills transfer techniques instead of didactic teaching are enjoyed more by the participants. Evaluations reveal they loved ‘hands on’ learning instead of ‘chalk and talk’.  The Head of the nursing Polytek is most appreciative of FOHG’s input and has upgraded the methods accordingly.

Since the opening of the Muder Ignancia Hospital, the MNH team have provided seminars to both the staff and those of the SoE General Hospital.

Reference list:

Australian Government. Australian Institute of Health and Welfare (AIHW): Maternal Deaths in Australia 2012 -2104

Australian Institute of Health and Welfare (AIHW) 2017, Perinatal deaths in Australia 2013–2014. (Released 29 May 2018)

GOI, Indonesian Ministry of Health, Health Research and Development. Health of Indonesia from the 2018 census .

Personal Comment : Dr Lorens, coordinator of ‘Maternal and Neonatal Auditing’ in West Timor.

Personal comment: Ibu Since, Head Midwife, Ende General Hospital and District.

Personal comment: Ibu Onda, Head Midwife, Nagakeo General Hospital and District