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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

Australian perinatal mortality by state.

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

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

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The Canberra couple funding a maternity hospital in West Timor

Read the Full Article on the Canberra Times here

No-nonsense and down-to-earth, Canberra obstetrician Dr David O’Rourke is well known to local families, having delivered about 3000 babies over the last decade.

He and his wife Sue-Ann are also focused on newborns beyond Canberra. The couple has for the last five years funded the construction and operation of a maternity hospital in West Timor.

The couple has plans to double the size of the Mother Ignacia Hospital to 50 beds, so it can also cater for general admissions but continue to focus on child and maternal health.
 
 

The basic premise is that for any surgical case taken on in Canberra by Dr O’Rourke, he foregoes any out-of-pocket expenses that may usually be paid to him by the patient.

He instead asks his patient to make a tax-deductible contribution towards the hospital in West Timor.

“I’m very proud of David,” Sue-Ann says.

“I’ve never heard of another doctor doing it this way, foregoing their own income in order to help others.”

A former country GP in places such as Moree, Orange, Mudgee and Goulburn, David retrained as an obstetrician and gynaecologist in Canberra and Adelaide more than a decade go.

And, as is often the case, a stroke of serendipity sent David and Sue-Ann on their journey to West Timor.

It is part of the island of Timor, which is less than 700 kilometres across the Timor Sea from Darwin, but a world away from the privilege and easy life of Australia.

The people in West Timor live in poverty, suffer from malnutrition, have limited education and must make do with an under-resourced health system. Having a baby is a perilous experience, for both mother and child.

When he was training in Adelaide in 2007, David needed to have a skin cancer removed from his face. His surgeon, Dr Peter Riddle, had a long history of clinical work in West Timor and an association with the Flinders Overseas Health Group, with whom the O’Rourkes would eventually collaborate.

The Flinders Overseas Health Group is a collection of volunteer health professionals across Australia including doctors, nurses, pharmacists and laboratory scientists who give their time and expertise in the Eastern Indonesian province of Nusa Tenggara Timur, which includes West Timor.

After that initial meeting with Dr Riddle, David O’Rourke became involved with the Flinders group and travelled to West Timor for the first time in 2009, to offer some assistance in educating the local medical staff.

Sue-Ann remembers how life-changing that visit was for all of them. The level of poverty and the desperate need were almost overwhelming. The health facilities were borderline life-threatening.

“David came home really shocked by the conditions, hugely shocked,” she says.

“They were rewashing surgical gloves and repowdering them. Washing out catheter tubes and reusing them. The power would go out and the generator would kick in so the surgeon would have to operate with a head torch. There were squat toilets with mould all over them.

“Until you experience the conditions, you can’t understand the level of poverty.”

David also learned about the long-term goal to build a maternity hospital in the town of Soe. And that gave him something to focus on

“He said, ‘You know what? They need money, investment, infrastructure. They don’t need us to tell them how to do it our way, they need the money to do it their way,” Sue-Ann remembers.

David was, and remains, pragmatic about what could be done.

“It made us realise our society is so good. Things we take for granted and are just routine, are certainly not taken for granted there,” he says.

“It’s inequality by geography. If you’re born here, everything is fine, everything is laid on.

“It’s inequality by geography. If you’re born here, everything is fine, everything is laid on.”

Dr David O’Rourke

“You can’t change the world but as an individual you can make some difference in some way.

“But you have to let the local culture run the show. You can’t introduce a western-style practice over there.”

While David, 49, and Sue-Ann, 47, are not religious, they formed a strong bond with a local Catholic order of nuns, Religious of the Virgin Mary, who were passionate about getting the hospital built.

The formidable Mother Superior Sister Yasinta had previously, over many years raised the issue of high mortality rate for mothers and infants in West Timor as a result poor family structure, poverty, primitive transport and inadequate facilities.

It led to a collaboration between the O’Rourkes, the nuns and the Flinders Overseas Health Group.

The O’Rourkes would provide all the funding for the maternity hospital, if Flinders could help with the logistics and on-the-ground contacts.

How they would fund the hospital was fairly unique and undoubtedly altruistic.

“David said to me: ‘ What if our patients didn’t pay us?’. I thought, ‘OK, this is a problem. We need to eat’,” Sue-Ann says with a laugh.

They instead came up with part of his fees being donated to the hospital.

That worked well and with a lot of persistence and help from the local community, the Mother Ignacia Maternity Hospital was opened in 2016.

Last year, a sponsorship program called One Birth at a Time was added. For a $200 donation, a mother and family could have care for the birth of their child when they might otherwise have none.

The $200 donation covered free antenatal clinic visits, a supervised delivery at the hospital and a health pack to take home with the baby.

Birth sponsors are contacted by the hospital via email and send a letter of appreciation, birthing report and photos.

It’s hoped the hospital can eventually be self-sustaining with funding from the Indonesian government.

The nuns still help to run the hospital. It is ostensibly a secular service. Patients do not have to be Catholic to attend it.

“Their mission is to serve people. They treat everyone equally and I love that,” Sue-Ann says.

David and Sue-Ann have four children: Lily, 14, Jack, 10, and twins Harry and Tom, 6.

Their twin pregnancy was uncomplicated but still required plenty of antenatal care visits, multiple ultrasounds, spinal anaesthesia, elective caesarean section and special care nursery for 10 days for the new babies. All provided under the supervision of obstetrician, anaesthetist, paediatrician and midwifery and nursing staff.

“All this is routine and taken for granted in Australia, and the disparity of this and maternity care in West Timor (and many other parts of the world) is strikingly obvious,” David says.

They both understand the relative luxury of the Australian health system.

“I get upset when I think about it,” Sue-Ann says.

“I went for my first visit to the [West Timorese] hospital in February and these people are so gracious and grateful for anything, for any sort of help.

“We over here, get upset if everything is not perfect. Over there, they don’t even get upset if a baby doesn’t make it, they accept that.”

Tragically during Sue-Ann’s visit, a mother in labour died trying to get to the hospital because she could not cross a flood-swollen river.

It’s a struggle to understand such hardship exists on Australia’s doorstep.

“It’s a seven-hour flight from Sydney. They are one of our closest neighbours. It’s just abject poverty,” she says.

“I remember being in a cafe once and complaining I got the wrong order and David looked at me and said, ‘You know what? In Indonesia, they don’t get a choice. I thought, ‘Yes’ . That put me back in my box straight away.”

The hospital currently has two full-time doctors, nurses, midwives and ancillary staff and an ambulance. The Flinders Overseas Health Group recently donated an ultrasound machine.

“The eventual aim is for the Mother Ignacia Hospital to be a self -sustained health facility with 25 beds for general admissions and 25 beds for maternity admissions,” David says.

“It will be a centre for clinical activity to benefit the poor people of Soe as well as a facility for visiting teams from Australia to visit and deliver educational programs that will achieve sustainable health through education.”

This Mother’s Day, David is on-call so the family will probably have breakfast at their local cafe. Their thoughts will also be with the new mums embarking on the journey of motherhood in West Timor.

When asked what she enjoys about being a mother, Sue-Ann jokes: “I enjoy them when they’re asleep”.

But seriously.

“I just see the future. I just see a positive future, the continuation of the good in the world and I’m happy to pass on that ethos of helping the underprivileged.

“We have so much. Too much. We don’t need it.

“Kids keep you real. They keep you in the moment.”

In the end, the couple is motivated by a quote from Sir Winston Churchill: “We make a living by what we get. We make a life by what we give”.

  • For more details on the Mother Ignacia Hospital or to make a donation, go to www.muderignacia.com or ring Dr O’Rourke’s office on 6285 1930.