Friday, July 08, 2011

Serang, West Java

Sign for Midwife Ratini, next to the poskesdes.

Mother's waiting their turn for an interview.

Group photo in front of the poskesdes - including the village midwife and the village health workers.

An early morning was the beginning to our last field visit, Serang. I can’t say that waking up at 4:30 and leaving at 5:15 was my ideal travel schedule, but knowing that I was one day closer to being finished with these interviews was motivation enough. Don’t get me wrong, the interviews have been fascinating. But after conducting 230 of them, and knowing that we have between 60 and 70 to go feels great. It’s been a frustrating past two weeks and our past two sites have been difficult. I dozed between Jakarta and Serang, normally a two hour trip but it only took us an hour and half since we left before there was any traffic. We arrived at what I would later realize was the MCHIP office and I was eagerly greeted by many “hellos” which confused me as I was waking up. After walking into the office and barely noticing the MCHIP sign on the wall, everyone interrupted a conference call with the States (which I can totally imagine being in the States on that conference call and being like, “what in the world is going on?”) to greet me and I sunk into a leather loveseat and listened to their workplan for the month of July. The MCHIP team in Serang is supported by John Snow, Inc., which I’ve heard great things about! The project manager/leader is actually a dentist by training, and the entire team is very well organized. At 8 AM, we headed to the District Health Office to meet the Director and discuss our purpose for being in Serang. Since he had already received the official letter from MCHIP, he told us that he was really pleased that we were doing this research. He then, unlike any other DHO has done, explained to me that in Serang – and much of West Java – culture and traditions play a huge role in people’s daily lives. Many women want to stay home to be comfortable and surrounded by their families, including grandmothers and grandfathers, to deliver their babies. While there has been a shift toward using more midwives than TBAs, TBAs are still very present at the village level. This was a nice backdrop to have before beginning our interviews. He also acknowledged that the results of our research will be very important for future planning in the district. Yes, another district that cares and wants to use the results to put into action! After our meeting with the DHO we left for Barugbug.

Our drive began through the city where Isti pointed out good salons and restaurants to dine at. She previously spent two months here with another midwife volunteer who worked on training midwives. We continued, me not really caring about my surroundings. After maybe 10 km, or so, we turned off toward Barugbug and the entire landscape changed. All of a sudden we were surrounded by banana and palm trees and small houses on the side of the road. After a few km, a mountain appeared through the morning mist/haze, and I looked around confused, thinking, “Wasn’t I just in the city?” I felt like we fell into a totally different dimension of the district we were in. We arrived at the Padarincang puskesmas and picked up the midwife coordinator before heading to Barugbug. We retraced the road that we had just taken and turned left down a narrow and steep alley. The “road” soon became a horrible mess of rocks and a previously paved road. We traveled through a small village until we reached a stream and a bridge. After crossing the bridge, the landscape again changed full of green rice fields and tall palm trees and mountains in the background, one one side, and a badly polluted stream on the other. I finally felt that I had found the Indonesia I was looking for. Where has this quaintness been in the past six weeks? And why did it take until my last field visit to find it? Admitedly, I’m happy that Serang wound up being our last field visit instead of our first. If this landscape had been my first day of field visits and the rest had gone downhill, I would have been really disappointed. Though, Minas was really nice, it was just all those oil pipelines that ruined the scenery for me. I digress….

Woman walking along the road from the rice fields back to the village

The bright green grass and mountainous - ok, hilly - scenery surrounding what I presume to be a resting area/hut in the middle of the rice field.

When we arrived at Barugbug, we went to the poskesdes where a posyandu had just ended. It took us a few minutes to get set up because the midwife was still administering vaccinations, so I eagerly took out my camera and started shooting mothers and babies. It wasn’t long before I was called in to start interviewing though. We interviewed 13 women today and it took almost four hours. This after our last day of interviews in Bojonegoro was 12 women and only took two hours. It was a challenging day for us, and the beginning of what will likely be a challenging week. The education system in West Java must be terrible compared to the two other regions we visited. We have one question, that depending on the context, asks women why they chose to deliver where they did or what might encourage them to deliver at a facility, and we offer them a list of 15 possible choices. We definitely ran into some problems when we started our interviews because the list was difficult to understand. For example, one of the options is “Distance” but this means different things if you’re choosing to deliver at home because you don’t have to go anywhere or if you’d be encouraged to go to a facility if it were closer. After experiencing these difficulties (mainly in West Java) we wrote out very clearly what the options meant for both a non-facility and facility response. Despite making it as clear as possible and having had no problems in the last 70 interviews, we find ourselves again in West Java where the women get confused and flustered by the list and many cannot even read the options or understand what they mean. This makes our research really challenging because technically we’re supposed to ask every question the same way. But when someone doesn’t understand the question, are you just supposed to pass it by? So we kind of danced around these questions today and tried to come up with a plan for making sure these women understood the question. What’s even more frustrating is when the women clearly do not understand the question, and just start naming off responses. I’m not sure why they don’t say, “I’m sorry, I don’t understand this question, can you please explain it better?” - we encourage them to ask questions if something isn't clear. It must be pride, but their pride is ruining my data! An example of this, from today, is a woman saying that she would be encouraged to go to a facility because she knows it cleaner than delivering at home. But in the next question, asking if she would recommend to her friends/family to deliver at home, she says yes and then cites cleanliness at home, to support her recommendation. These situations make for a really long day, especially when we’re used to these interviews taking 9-12 minutes and they are drawn out to 15-20 minutes. Doesn’t sound like a huge change, but since I can’t jump in and say, “Okay, this is what we’re trying to say…” I get frustrated as well. That said, I was just really happy to be sitting in this idyllic village and these issues weren't affecting me like they had before (I will write more about what happened in Kawawang).

Mothers and babies.

More mothers and babies.

We had some interesting stories today, which isn’t necessarily the case every day. I can imagine that since we’re in a region that has such strong ties to culture and tradition, that the experiences of women here will surprise me a little every day. The majority of women that we interviewed today delivered at home, either with a TBA or midwife. Two of the women had prolonged labors. One young woman, 20 years old, was in labor for three days before the TBA finally referred her to the puskesmas. Three days? I’m curious what the TBA thought after the first 24 hours - did she think she had a solution to the labor? And what about 48 hours? Another woman, pictured below, is 46 years old and has eight children. Her latest birth was a few months ago and she spent five days in labor. What? Five days? On her fifth day, with no hope in sight of delivering this baby, the imam at the mosque came to her house and told her that she must have a ghost around her which was prohibiting her from delivering her baby. He gave her some “holy water” – I don’t know what it’s called in Islam – and she miraculously delivered her baby the same day.

46 year old woman, pictured with four of her eight children. She survived five days in prolonged labor.

Our first interview of the day.

The only issue I take in all of this is wondering if the TBAs and village midwifes are really upholding their oath of protecting women’s lives and ensuring their safety by getting them the services they need when they need them. I was told, “Well, maybe the women don’t want to go to the facilities.” In my opinion, it’s the responsibility of the TBAs and midwives to inform – and even possibly force – these women to get to the facility to deliver their babies before three or five days pass. I’m amazed that after five days in prolonged labor that this woman didn’t die. These are the instances that I wish culture and tradition weren’t so strong and that TBAs and midwives could say, “You’re going to die if you don’t go to the hospital” in order to make these women realize how grave their situation is.

I was sitting behind the window to this boys right, and he and other young children kept playing peek-a-boo with me. To win their hearts over, I take their pictures and then surprise them by showing them their photo on my camera. It works, almost, every time.

I loved this baby who, though asleep, looks so distressed with her little hand covering her face.

A young girl who thought she was afraid of me until I took her photo.