Saturday, July 02, 2011

Women in Bojonegoro know how to deliver in facilities

My favorite respondent in Bojon: She's 45 and her daughter was born 4 months ago. Her daughter's older siblings are 14 and 21. With this unexpected surprise, we can definitely say that family planning was needed in this household.

But she's SO adorable!

Two districts down, two to go. I was excited about our trip to Bojonegoro (which I’ll refer to as Bojon) because it meant flying to the opposite side of Java and seeing how this place runs it’s maternal and child health program. We flew into Surabaya, a large port city and the second largest city in Indonesia (and one of the largest red light districts in Asia, I just found out). We didn’t see the city, but started out to Bojon. Despite Google maps telling me it was 110 km and about 2 hours, it turned out to take 3 hours to get there. The road was good, part of the trip was on a toll road. The road after the toll road was quaint – it seemed like we were driving through small towns along the way, each had a beautiful mosque adorning the road side, most under construction of some sort. The other side of the road had a train track where several trains passed us, passengers hanging out of the doors probably trying to get a reprieve from the stifling heat inside. We arrived in Bojon after sunset, with a light rain and headed to the hotel. Pretty nice hotel, but infested with mosquitoes which required me to go on a killing spree before I could relax. The ceiling was too high, so I often stood on a chair, throwing something at the ceiling as I hurled myself off the chair. It took awhile, but I got most of them! I settled into an evening of CSI and NCIS reruns on TV.

The next morning, per usual, we went to the District Health Office to meet the staff, discuss our research and get their blessings. The women running the DHO were amazing – they knew all sorts of statistics about Bojon, which most other DHOs can’t give me. I was pretty immediately impressed. I found out the following:

  • Bojon Population: 1.2 million
  • 430 villages
  • # of Public Hospitals: 3
  • # of Private Hospitals: 6
  • # of Puskesmas: 36
  • # of Pustu (Assisted Puskesmas): 68
  • # of Ponkesdes (a new facility we had not yet heard of: a facility with a midwife and a nurse): 100
  • # of Polindes: 300
  • % of women who use TBAs for delivery: 2

I also found out that between 2007 and 2010, there was an increase in MMR to 90 per 100,000, despite a reported facility-birth rate of over 70%. 70%? That’s amazing. Obviously this district is doing something right to ensure a facility-birth rate of over 70%. I felt like maybe we had come upon a district that, despite decentralization, was really paying attention to its women and children and not building bridges and roads with government money. This seemed like a really great start to our week.

A note here about Bojon’s definition of facility and the way we’ve defined facility for our research. They have included all of the facilities above (Hopsital, Puskesmas, Pustu, Ponkesdes and Polindes) in their 70%+ numbers. Our survey doesn’t include Ponkesdes, Polindes and really shouldn’t include Pustu either. None of these facilities have more than one provider (a midwife) in case of emergency or complication. That said, the Polindes that we found in Bojon were incredible. They were new, clean and well stocked with equipment and medicines. Much more so than some hospitals I’ve seen and certainly more than Polindes we’ve seen in other districts that amounted to no more than a small two roomed facility that had nothing inside of it. All this is to say that even though Bojon quotes this 70%+ number, we should still be able to find non-facility births, either at home or at these facilities that aren’t included in our research. After the first two days of visiting Polindes, where we should have found some non-facility births, but whose midwifes encouraged all the women to go to her private birthing center instead, we hadn’t found any. With this problem, we went to the DHO after we finished our interviews to discuss how to change our strategy of which villages to visit because we needed a certain number of facility, non-facility and pregnant respondents. When we reported to the DHO what had already happened, she yelled to her assistants to bring some documents to her. All of a sudden, the rate of facility-births in Bojon district was 94.7%, not the 70%+ that was quoted two days before. Okay, technically 95% is more than 70%, but there was definitely a problem in the way these numbers were presented to me and I was frustrated. Regardless, since the above mentioned facilities are part of the 95% number, but not part of our research parameters, that still meant that we should be able to find women that had delivered in these facilities, specifically any one of the 300 Polindes that I was told existed. The DHO staff seemed to think I was crazy and that I wasn’t for some reason understanding that we couldn’t find these women. I, at the same time, seemed to think they were crazy trying to push off a 95% facility-birth rate, while telling me at the same time that their MMR increased. To top it all off, my translator was driving me crazy by telling me that their numbers had to be correct, they had the data to back it up! She said she didn't believe it, but they had the data. Right, like data is never wrong. This comes from someone who is supposed to be helping me gather this research and later analyze the data. I told her I really didn’t care what their numbers and their data said, that the numbers didn’t jive. Over and over I was told, “Well, you’re not going to be able to find the numbers of non-facility women that you’re looking for,” while I repeated to them over and over that we needed about 23 non-facility women to interview. I could have probably backed down, but I was fighting for the statistical significance of my data (and my pride)! I’m not really sure how things worked themselves out in the end, since I was so pissed that I was being told that out of 400 non-facilities, I wouldn’t be able to find 23 women.

The first woman I saw feeding her child with a bottle. She is unable to breastfeed.

Quite the opposite of the woman above, this woman is overfeeding her baby to the point of obesity. This baby was only 3 months old and his mother had a hard time carrying him around. She reported that she was only feeding him breastmilk.

In the end, we wound up finding our women, though only 20 of them. Most of them had delivered at the Polindes, though there were a few home births mixed in there. We visited a variety of puskesmas, polindes and private midwives clinics. There was definitely an energy about the women in Bojon. They all seemed to have really good reasons for going to facilities, which means that someone is doing their job educating the women about the need to deliver in a facility. The women we found that delivered at home did so either because they didn't have money and didn't know about jampersal (the government policy to pay for births at facilities) or didn't make it to a facility in time.

Polindes in Mojosari

Delivery room at the polindes.

Actual trash cans outside of the polindes and along the road in this village

Village map in Sidobandung - green, yellow and red stickers all show where pregnant women live and classify them by normal, low-risk and high-risk pregnancies. The map is updated as women become pregnant.

Polindes in Ngunut: A map of the village including locations for the polindes, mosque, and showing rivers and bridges.

In the labor room at the polindes in Ngunut. I guess a rusty nail on the wall is as good as place to leave a stethascope

This is an emergency medical kit with essentials needed during labor and if there are minor complications. This one is quite empty, perhaps the reason that the midwife takes all the pregnant mothers to her pri

We conducted fewer interviews here than in the other two districts – only 68 compared with 82 and 74. For whatever reason, the situation at the DHO completely frustrated me and put quite a sour note on my week. Bojon made me feel completely over being in Indonesia and completely ready to go home. I’d never been happier to hear the words, “Welcome to Jakarta” from the airline pilot. I needed the comfort of my Jakarta house with swimming pool and good food before heading out to our last district: Serang.